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Function
Nancy Haugen PhD, RN
Ulrich & Canale's Nursing Care Planning Guides (NANDA), CHAPTER 4, 116-225
ASTHMA
Asthma is a disorder characterized by intermittent and reversible obstruction of the airways. This
airflow obstruction is caused by bronchial hyperresponsiveness and inflammation of the airway
mucous membranes. Allergens enter the airway and initiate the inflammatory cascade. Mast cells
found in the basement membranes of the bronchial walls degranulate and release inflammation
response mediators, which cause increased capillary permeability and vasodilation, and
recruitment of eosinophils, lymphocytes, and neutrophils. The response leads to the production
of thick, tenacious mucus that blocks the airways. Combined with the bronchial
hyperresponsiveness and capillary vasodilation and permeability, intake of air significantly
decreases, and air is trapped in the lungs below the obstruction. Chronic inflammation leads to
remodeling of the bronchial walls. The bronchial walls hypertrophy, and mucus-producing cells
undergo hyperplasia.
Asthma attacks are variable and unpredictable, range from mild to severe, and differ from client
to client. Clinical manifestations of an asthma attack include dyspnea, wheezing, chest tightness,
tachycardia, sweating, cough, tightening of neck muscles, and use of accessory muscles to
breathe. The client may also have an audible wheezing or whistling on exhalation. Indications
that asthma is becoming worse include an increase in the frequency and severity of asthma
attacks and an increased need to use bronchodilators.
There is no clear indication why some people get asthma and others, exposed to the same
conditions, do not. It is possibly due to a combination of environmental and genetic factors.
Triggers for an asthma attack also vary from client to client and may include airborne allergens
and air pollutants, viral respiratory infections, cold air, stress, medications (i.e., nonsteroidal anti-
inflammatory drugs [NSAIDs]), exercise, gastroesophageal reflex disease, smoke, and
occupational factors.
This care plan focuses on care of the adult client with asthma who is hospitalized during an
exacerbation of the illness. Much of the information is applicable to clients receiving follow-
up care in an extended care facility or home setting.
1
OUTCOME/DISCHARGE CRITERIA
The client will:
1.
2.
3.
4.
5.
2
Nursing Diagnosis IMPAIRED RESPIRATORY
FUNCTION *
* This diagnostic label includes the following nursing
diagnoses: ineffective breathing pattern, ineffective airway
clearance, and impaired gas exchange.
Definition: Inspiration and/or expiration that does not provide adequate ventilation; inability to
clear secretions or obstructions from the respiratory tract to maintain a clear airway
Related to:
Increased rate of respirations associated with fear and anxiety, and feeling of air hunger
Related to:
3
Stasis of secretions associated with:
Impaired ciliary function resulting from loss of ciliated epithelium (occurs with
inflammation, destruction, and fibrosis of bronchial walls)
Related to:
CLINICAL MANIFESTATIONS
Subjective Objective
Rapid, shallow respirations; abnormal breath sounds wheezing;
Reports of restlessness;
cough; use of accessory muscles when breathing; significant
irritability; somnolence;
decrease in oximetry results; abnormal arterial blood gas values;
chronic cough; chest tightness
reduced activity tolerance
RISK FACTORS
Genetics
Smoking
Allergies
4
Environmental factors
DESIRED OUTCOMES
The client will maintain adequate respiratory function as evidenced by:
a.
b.
Decreased dyspnea
c.
d.
e.
f.
NOC OUTCOMES
Respiratory status; airway patency; respiratory status: ventilation; respiratory status: gas
exchange
NIC INTERVENTIONS
Respiratory monitoring; airway management; chest physiotherapy; cough enhancement; oxygen
therapy; medication administration; ventilation assistance; cough enhancement; fear and anxiety
reduction
5
NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms Early recognition of signs and symptoms of ineffective
of impaired respiratory function: breathing patterns allows for prompt intervention.
Rapid, shallow
respirations
Rapid, shallow respirations do not provide adequate
ventilatory support. Difficulty with breathing and the need to
sit up to breathe, as well as use of accessory muscles, lead to
Dyspnea, orthopnea client fatigue and further decline in respiratory status.
Changes in the characteristics of breath sounds may be due to
airway obstruction, mucus plugs, or retained secretions in
Abnormal breath sounds larger airways. Wheezing is associated with bronchospasms.
(e.g., wheezes, crackles)
Muscle fatigue/weakness may impair effective clearance of
secretions.
Cough effectiveness
Restlessness, irritability
Restlessness, irritability, and change in mental status
or level of consciousness indicate an oxygen deficiency
and require immediate treatment.
Confusion, somnolence
6
RATIONALE
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to improve respiratory
status.
Positioning in semi-Fowler's position promotes
Place client in a semi-Fowler's position. D optimal gas exchange by enabling chest
expansion and diaphragm excursion.
Instruct client in breathing exercises focusing on These techniques help clients decrease the
hypoventilation, breath holding after exhalation, need for beta 2 -agonists and inhaled
and breathing through the nose. corticosteroids.
Instruct client in exercises involving shoulder
rotations and arm lifts performed in sync with This technique helps to expand the lungs.
breathing.
The irritants in smoke increase mucus
production, impair ciliary function, and can
Discourage smoking. cause inflammation and damage to the
bronchial and alveolar walls; the carbon
monoxide decreases oxygen availability.
Maintain activity restrictions and increase Conservation of energy through activity
activity as allowed and tolerated. restrictions allows energy to be focused on
7
RATIONALE
breathing. Increasing activity as tolerated
helps to mobilize secretions and promotes
deeper breathing.
Perform actions to reduce fear and anxiety (e.g.,
assure client that staff members are nearby;
The experience of anxiety during an asthma
respond to call signal as soon as possible;
attack can exacerbate the attack.
provide calm, restful environment; instruct in
relaxation techniques). D
Maintaining adequate hydration decreases the
Maintain client fluid intake of at least 2500
viscosity of secretions and improves ciliary
mL/day unless contraindicated. D
action in removing secretions.
Dependent/Collaborative Actions
Implement measures to improve respiratory
status.
Beta- 2 agonists are the treatment of choice for
Administer beta- 2 adrenergic agonists inhaled
an asthma attack because they relax airway
during an acute attack and oral for ongoing
smooth muscles and decrease
therapy. D
bronchoconstriction.
Related to:
8
Tissue hypoxia associated with impaired gas exchange
Difficulty resting and sleeping associated with dyspnea, excessive coughing, fear,
anxiety, frequent assessment and treatments, and side effects of medication therapy (e.g.,
some bronchodilators, corticosteroids)
Increased energy expenditure associated with strenuous breathing efforts and persistent
coughing
CLINICAL MANIFESTATIONS
Subjective Objective
Verbal report of Abnormal heart rate or blood pressure (B/P) response to activity; exertional
fatigue or discomfort or dyspnea; electrocardiographic changes reflecting dysrhythmias
weakness or ischemia; unable to speak with physical activity
RISK FACTORS
Smoking
Malnutrition
Allergens
Insomnia
DESIRED OUTCOMES
9
The client will demonstrate an increased tolerance for activity as evidenced by:
a.
b.
Ability to perform ADL without exertional dyspnea, chest pain, diaphoresis, dizziness,
and significant changes in vital signs
NOC OUTCOMES
Activity tolerance; endurance, fatigue level; vital signs; asthma: self-management
NIC INTERVENTIONS
Activity therapy; energy management; oxygen therapy; nutrition management; sleep
enhancement; cardiac care; cardiac rehabilitation; teaching regarding prescribed activity
NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms of activity intolerance:
10
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to promote rest and/or Cells use oxygen and fat, protein, and
conserve energy (e.g., maintain prescribed activity carbohydrates to produce the energy
restrictions, minimize environmental activity and needed for all body activities. Rest and
noise, provide uninterrupted rest periods, assist with activities that conserve energy result in a
care, keep supplies and personal articles within easy lower metabolic rate, which preserves
reach, limit the number of visitors, use shower chair nutrients and oxygen for necessary
when showering, sit to brush teeth or comb hair). D activities.
Implement measures to promote sleep (e.g., elevate
head of bed and support arms on pillows to facilitate
Sleep replenishes a client's energy and
breathing, maintain oxygen therapy during sleep,
feelings of well-being.
discourage intake of fluids high in caffeine in the
evening, reduce environmental stimuli). D
Altered respiratory function such as
Implement measures to decrease excessive excessive coughing can lead to inadequate
coughing and frequency of asthma attacks (e.g., tissue oxygenation, which results in less
protect client from exposure to irritants such as efficient energy production and a reduced
smoke, flowers, and powder; avoid extremely hot or ability to tolerate activity. Improving
cold foods/fluids). D respiratory status increases the amount of
oxygen available for energy production.
Excessive intake of nicotine and caffeine
Discourage smoking and excessive intake of
can increase cardiac workload and
beverages high in caffeine such as coffee, tea, and
myocardial oxygen utilization, thereby
colas.
decreasing oxygen availability.
Perform actions to improve respiratory status (e.g.,
Improvement of respiratory status is done
place client in semi- to high-Fowler's position;
to relieve dyspnea, decrease frequency of
instruct client to deep breathe or use incentive
asthma attacks, and improve tissue
spirometry every 1 to 2 hours; maintain bed rest as
oxygenation.
ordered; and use oxygen as needed). D
Perform actions to maintain adequate nutritional
status (e.g., increase activity as tolerated potentially
improving appetite; encourage a rest period before Adequate nutritional status is important in
meals to reduce fatigue; assist with oral hygiene order to maintain ADL.
before meals; maintain a clean environment and a
relaxed, pleasant atmosphere). D
Instruct a client to: Changes in a client's activity tolerance
should be reported immediately.
Assessment of the change will allow for
timely diagnosis of the cause and
Report a change in the frequency and subsequent treatment.
consistency of asthma attacks.
11
RATIONALE
Dependent/Collaborative Actions
Consult appropriate health care providers (e.g.,
Notifying the appropriate health care
respiratory therapist, physician, dietitian) if signs
provider allows for modification of the
and symptoms of activity intolerance persist or
treatment plan.
worsen.
CLINICAL MANIFESTATIONS
Subjective Objective
Verbalizes inability to manage illness; verbalizes inability Increased frequency and intensity of
to follow prescribed regimen asthma attacks
12
RISK FACTORS
Cognitive deficit
Financial concerns
Smoking
NURSING ASSESSMENT
RATIONALE
NOC OUTCOMES
Knowledge: treatment regimen; knowledge: energy conservation; knowledge: treatment
procedure(s); knowledge: health resources; knowledge: illness care; compliance behavior; health
beliefs; perceived ability to perform: knowledge of treatment regimen
NIC INTERVENTIONS
13
Health system guidance; teaching: individual; teaching: disease process; teaching: prescribed
activity/exercise; teaching: prescribed medication; self-modification assistance; values
clarification; discharge planning; medication management; smoking cessation assistance
THERAPEUTIC INTERVENTIONS
RATIONALE
Desired Outcome: The client will identify ways
to prevent or minimize respiratory problems.
Independent Actions
Instruct client in ways to maintain respiratory
health:
Good general health supports the individual's
Maintain overall general good health ability to fight off infection.
(e.g., reduce stress, eat a well-balanced
diet, obtain adequate rest).
Stop smoking.
Air pollution in high levels is harmful to
Remain indoors as much as possible persons with existing lung disease.
when air pollution levels are high.
14
RATIONALE
Increases a client's potential for a respiratory
Avoid prolonged close contact with infection
persons who have respiratory infection.
Immunizations help to prevent further
Receive immunizations against influenza respiratory disease.
and pneumococcal pneumonia.
THERAPEUTIC INTERVENTIONS
RATIONALE
Desired Outcome: The client will verbalize ways
to maintain adherence to the medication regimen
including rationale, food and drug interactions,
side effects, methods of administration, and the
importance of taking medications as prescribed.
Independent Actions
Educate the patient about the disease process and
treatment of asthma:
Understanding of the disease and its
Explain asthma in terms the client can treatment plan provides patients with a sense
understand; stress that adherence to the of control, and they will be more likely to
treatment plan is necessary in order to comply with the treatment regimen.
prevent complications and reactivation of
the disease.
15
RATIONALE
16
RATIONALE
IgE antagonists
Leukotriene modifiers
Methylxanthines
17
RATIONALE
Lung Association, support groups).
THERAPEUTIC INTERVENTIONS
RATIONALE
Desired Outcome: The client will state signs and
symptoms to report to the health care provider.
Independent Actions
Instruct client to report the following to the health care
provider:
These clinical manifestations
Difficulty breathing, continued or increased cough, indicate an infection or super
or chest pain infection and should be reported to
the health care provider.
18
RATIONALE
Reinforce the importance of keeping appointments for Regular health care appointments
follow-up tests (e.g., blood work, chest radiographs) and are important to determine
physical examinations to determine effectiveness of the effectiveness of the medication
medication regimen and assess for side effects. regimen and assess for side effects.
The two conditions that comprise COPD are chronic bronchitis and emphysema. Chronic
bronchitis is characterized by a cough that persists at least 3 months of the year for 2 consecutive
years and an excessive production of mucus in the bronchi due to inflammation of the
bronchioles and hypertrophy and hyperplasia of the mucous glands. In contrast, emphysema is
characterized by dyspnea and a mild cough. The impaired airflow that occurs with emphysema is
related to loss of lung elasticity, narrowing of the terminal nonrespiratory bronchioles, and
destructive changes in the walls of the alveolar and/or respiratory bronchioles. Both chronic
bronchitis and emphysema are usually present in the person with COPD, although one of the two
usually predominates.
19
Causative factors of COPD include chronic irritation of the lungs by cigarette smoke, exposure
to air pollution and chemical irritants, and recurrent respiratory tract infections. In a small
percentage of cases of emphysema, the destruction of lung tissue by proteolytic enzymes is a
result of a genetic deficiency of alpha 1 -antitrypsin.
This care plan focuses on care of the adult client with COPD who is hospitalized during an
acute exacerbation. Much of the information is applicable to clients receiving follow-up care
in an extended care facility or home setting.
OUTCOME/DISCHARGE CRITERIA
The client will:
1.
2.
3.
4.
5.
6.
7.
8.
20
Verbalize an understanding of medications ordered including rationale, food and drug
interactions, side effects, methods of administering, and importance of taking as
prescribed
9.
10.
11.
Share feelings and thoughts about the effects of COPD on lifestyle and roles
12.
Identify resources that can assist with financial needs, home management, and adjustment
to changes resulting from COPD
13.
Related to:
Related to:
21
Decreased depth of respirations associated with weakness, fatigue, fear, anxiety, and
presence of a flattened diaphragm (a result of prolonged hyperinflation of the lungs)
Related to:
Destruction of the elastic fibers in the walls of the small airways (with
emphysema)
Impaired ciliary function resulting from loss of ciliated epithelium (occurs with
inflammation, destruction, and fibrosis of bronchial walls)
Decreased mobility
22
Impaired gas exchange NDx
Related to:
CLINICAL MANIFESTATIONS
Subjective Objective
Rapid, shallow respirations; abnormal breath sounds; chronic cough;
use of accessory muscles when breathing; increased anterior-
Reports of confusion;
posterior diameter; dyspnea; nasal flaring; central cyanosis (late
disorientation; restlessness;
sign); decreased expiratory and inspiratory pressure; decreased
irritability; somnolence;
minute ventilation and vital capacity; significant decrease in
chest tightness
oximetry results; abnormal arterial blood gas values; reduced
activity tolerance
RISK FACTORS
Smoking
Obstruction of airways
23
Occupational dust and chemicals
DESIRED OUTCOMES
The client will maintain adequate respiratory function as evidenced by:
a.
b.
Decreased dyspnea
c.
d.
e.
f.
NOC OUTCOMES
Respiratory status; airway patency; respiratory status: ventilation; respiratory status: gas
exchange
NIC INTERVENTIONS
Respiratory monitoring; airway management; chest physiotherapy; cough enhancement; oxygen
therapy; medication administration; ventilation assistance; cough enhancement; fear and anxiety
reduction
24
NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms Early recognition of signs and symptoms of ineffective
of impaired respiratory function: breathing patterns allows for prompt intervention.
Rapid, shallow
respirations
Rapid, shallow respirations do not provide adequate
ventilatory support. Difficulty with breathing and the need to
sit up to breathe, as well as use of accessory muscles, lead to
Dyspnea, orthopnea client fatigue and further decline in respiratory status.
Changes in the characteristics of breath sounds may be due to
Abnormal breath sounds airway obstruction, mucus plugs, or retained secretions in
(e.g., diminished or larger airways.
absent, rhonchi, wheezes)
Muscle fatigue/weakness may impair effective clearance of
secretions.
Cough effectiveness
Confusion, somnolence
25
RATIONALE
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to improve
respiratory status:
Maintain supportive
environment.
The client's anxiety may increase if left alone during
Don't leave client during periods of respiratory distress.
periods of acute respiratory
distress.
Decreases client's feelings of being in an enclosed area,
which can increase anxiety.
Open curtains and doors.
26
RATIONALE
desired. D
These techniques help clients slow their pace of
Instruct client in and assist with breathing, which makes each breath more effective.
diaphragmatic and pursedlip
breathing techniques.
Increased fluid intake promotes thinning of secretions
Maintain client's fluid intake of and reduces dryness of the respiratory mucous
at least 2500 mL/day unless membranes.
contraindicated. D
Instruct client to avoid intake of Gas-forming foods and carbonated beverages can cause
large meals, gas-forming foods abdominal bloating, which places pressure on the
(i.e., cauliflower, beans, diaphragm and reduces lung expansion.
cabbage, onions, etc.), and
carbonated beverages.
27
RATIONALE
Dependent/Collaborative Actions
Implement measures to improve
respiratory status:
CNS depressants further depress respiratory status,
Avoid use of central nervous exacerbating the client's condition.
system (CNS) depressants. D
Corticosteroids
28
RATIONALE
Antimicrobials
Related to:
Nausea (can occur in response to noxious stimuli such as the sight of expectorated
sputum and as a side effect of some medications)
29
Increased metabolic needs associated with increased energy expenditure resulting from
strenuous breathing efforts and persistent coughing
CLINICAL MANIFESTATIONS
Subjective Objective
Weight loss; weight less than normal for client's age, height, and body
Report of painful
frame; abnormal blood urea nitrogen (BUN) and low serum prealbumin
oral mucous
levels; inflamed mucous membranes; pale conjunctiva; excessive hair loss;
membrane
poor muscle tone
RISK FACTORS
Lack of appetite
Poor diet
Lack of resources
DESIRED OUTCOMES
The client will maintain adequate nutrition status as evidenced by:
a.
b.
c.
NOC OUTCOMES
Nutritional status
NIC INTERVENTIONS
Nutritional monitoring; nutrition management; nutrition therapy; nausea management
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms of malnutrition
symptoms of malnutrition: allows for prompt intervention.
Weight significantly below a
client's usual weight or less than
normal for client's age, height, and
body frame
Pale conjunctiva
31
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Monitor percentage of meals and snacks
Monitoring a client's intake helps to identify when a
client consumes. Report a pattern of
patient is at risk for inadequate nutrition.
inadequate intake. D
Implement measures to maintain an
adequate nutritional status:
Interventions that relieve dyspnea allow the
Perform actions to improve oral patient to eat a meal without interruption or
intake: need to rest.
32
RATIONALE
33
RATIONALE
Dependent/Collaborative Actions
Implement measures to maintain an
adequate nutritional status:
o
Supplemental oxygen therapy relieves
dyspnea and the client's anxiety about and
Provide supplemental
preoccupation with breathing efforts and
oxygen during meals. D
increases the ability to focus on eating and
drinking.
o
Notifying the appropriate health care
Obtain a dietary consult to
professionals allows for a multidisciplinary
assist the client in selecting
approach to treatment.
foods/fluids that meet
nutritional needs, are
appealing, and adhere to
personal and cultural
preferences.
Administration of vitamins and minerals help to
Administer vitamins and minerals maintain nutritional status.
if ordered. D
Perform a calorie count if ordered. Report A calorie count provides information about the
34
RATIONALE
caloric and nutritional value of the foods/fluids the
client consumes. The information obtained helps the
information to dietitian and physician.
dietitian and physician determine whether an
alternative method of nutritional support is needed.
Consult physician about an alternative
method of providing nutrition (e.g., If the client's oral intake is inadequate, an
parenteral nutrition, tube feedings) if client alternative method of providing nutrients needs to be
does not consume enough food or fluids to implemented.
meet nutritional needs.
Related to:
Difficulty resting and sleeping associated with dyspnea, excessive coughing, fear,
anxiety, frequent assessment and treatments, and side effects of medication therapy (e.g.,
some bronchodilators, corticosteroids)
Increased energy expenditure associated with strenuous breathing efforts and persistent
coughing
CLINICAL MANIFESTATIONS
Subjective Objective
Abnormal heart rate or B/P response to activity; exertional discomfort or
Verbal report of
dyspnea; electrocardiographic changes reflecting dysrhythmias or ischemia;
fatigue or weakness
unable to speak with physical activity
35
RISK FACTORS
Exertional dyspnea
DESIRED OUTCOMES
The client will demonstrate an increased tolerance for activity as evidenced by:
a.
b.
Ability to perform activities of daily living without exertional dyspnea, chest pain,
diaphoresis, dizziness, and significant changes in vital signs
NOC OUTCOMES
Activity tolerance; endurance; fatigue level; vital signs; self-care: activities of daily living;
energy conservation
NIC INTERVENTIONS
Activity therapy; energy management; oxygen therapy; nutrition management; sleep
enhancement; cardiac care; cardiac rehabilitation; teaching regarding prescribed activity
NURSING ASSESSMENT
36
RATIONALE
Assess for signs and symptoms of activity intolerance:
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to promote rest and/or
conserve energy (e.g., maintain prescribed activity Cells use oxygen and fat, protein, and
restrictions, minimize environmental activity and carbohydrates to produce the energy needed
noise, provide uninterrupted rest periods, assist for all body activities. Rest and activities
with care, keep supplies and personal articles that conserve energy result in a lower
within easy reach, limit the number of visitors, use metabolic rate, which preserves nutrients
shower chair when showering, sit to brush teeth or and oxygen for necessary activities.
comb hair). D
Implement measures to promote sleep (e.g.,
elevated head of bed and support arms on pillows
Sleep replenishes a client's energy and
to facilitate breathing, discourage intake of fluids
feeling of well-being.
high in caffeine in the evening, and reduce
environmental stimuli). D
Implement measures to decrease excessive Altered respiratory function such as
coughing (e.g., protect client from exposure to excessive coughing can lead to inadequate
37
RATIONALE
tissue oxygenation, which results in less
efficient energy production and a reduced
irritants such as smoke, flowers, and powder; avoid
ability to tolerate activity. Improving
extremely hot or cold foods/fluids). D
respiratory status increases the amount of
oxygen available for energy production.
Excessive intake of nicotine and caffeine
Discourage smoking and excessive intake of
can increase cardiac workload and
beverages high in caffeine such as coffee, tea, and
myocardial oxygen utilization, thereby
colas.
decreasing oxygen availability.
Perform actions to improve respiratory status (e.g.,
place client in semi- to high-Fowler's position;
Improvement of respiratory status through
assist client to deep breathe or use incentive
increased lung expansion.
spirometry every 1 to 2 hours; maintain bed rest as
ordered; and use oxygen as needed). D
Perform actions to maintain adequate nutritional
status (e.g., increase activity as tolerated,
potentially improving appetite; encourage a rest Adequate nutritional status is important in
period before meals to reduce fatigue; assist with order to maintain ADL.
oral hygiene before meals; maintain a clean
environment and a relaxed pleasant atmosphere). D
Gradual increase will slowly improve
Increase client's activity gradually as allowed and
strength and ability in performance of
tolerated. D
activities.
Instruct a client to:
Dependent/Collaborative Actions
Consult appropriate health care providers (e.g.,
Notifying the appropriate health care
respiratory therapist, physician, dietitian) if signs
provider allows for modification of the
and symptoms of activity intolerance persist or
treatment plan.
worsen.
Related to:
Stasis of secretions in the lungs (secretions provide a good medium for bacterial growth)
CLINICAL MANIFESTATIONS
Subjective Objective
Increased respiratory rate; dyspnea; abnormal breath sounds (crackles, rales);
Verbalization of productive cough with purulent green or rust-colored sputum; chills and
pleuritic pain diaphoresis; fever; elevated white blood cell (WBC) count; significant
decrease in pulse oximetry values; worsening arterial blood gas values
RISK FACTORS
Stasis of secretions
Inhalation of pathogens
Debilitated state
Smoking
DESIRED OUTCOMES
The client will not develop pneumonia as evidenced by:
a.
39
Usual breath sounds and percussion note over lungs
b.
Absence of tachypnea
c.
d.
Afebrile status
e.
f.
g.
h.
Ability to perform ADL without increased dyspnea, chest pain, diaphoresis, dizziness,
and a significant change in vital signs
NOC OUTCOMES
Infection severity; immune status
NIC INTERVENTIONS
Infection protection; infection control; cough enhancement; airway management
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of pneumonia: Early recognition of signs and
symptoms of pneumonia allows for
40
RATIONALE
prompt intervention.
Pleuritic pain
41
RATIONALE
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to prevent pneumonia:
Equipment that is inadequately or
incompletely cleaned after use harbors
Replace or cleanse equipment used for bacteria may lead to an respiratory infection.
respiratory care as often as needed.
42
RATIONALE
Dependent/Collaborative Actions
Early administration of antibiotics at the first
If signs and symptoms of pneumonia occur,
sign of infection can decrease the impact and
administer antimicrobials as ordered. D
duration of the infection.
Consult other health care providers at the first Notifying the appropriate health care provider
signs and symptoms of an infection. allows for modification of the treatment plan.
43
BOOK CHAPTER
Respiratory Disorders
Frances D. Monahan PhD, RN, ANEF
Atelectasis
Overview/Pathophysiology
Atelectasis is a spontaneous collapse of alveolar lung tissue secondary to persistent
hypoinflation. It is most common following major abdominal or thoracic surgery and
results from hypoventilation of dependent portions of the lungs or inadequate clearing
of secretions. Atelectasis can be an acute or a chronic condition and occurs most often in
individuals with COPD. Postoperatively, atelectasis can be precipitated by the effects of
anesthesia, sedation, and decreased mobility. Other precipitating factors include mucus
plugs, foreign objects in the airways, pleural effusion, bronchogenic carcinoma, history
of smoking, and obesity. Atelectasis can lead to pulmonary infection.
Assessment
The clinical picture is determined by the site of collapse, rate of development, and size of
the affected area.
Diagnostic Tests
Oximetry
Bedside oximetry may demonstrate decreased O 2 saturation (92% or less).
44
Reveals higher density in affected lung, elevation of the hemidiaphragm on affected side,
and compensatory hyperinflation of adjacent lobes on the opposite side.
Collaborative Management
Management is aimed at preventing this condition in all patients. If atelectasis occurs
and is left untreated, the affected lung area eventually may become infected, fibrotic,
and functionless.
Chest physiotherapy
Mobilizes secretions.
Hyperinflation therapy
Expands partially collapsed lung areas and thereby improve gas exchange. Incentive
spirometry may be used at the bedside.
Analgesics
Reduce pain and thereby facilitate production of an effective cough.
Bronchoscopy
Patient is intubated and a fiberoptic scope is passed into the bronchi to visualize the
area and remove mucous plugs, retained secretions, or foreign objects.
O therapy
2
45
related to decreased lung expansion secondary to inactivity or omission of deep
breathing
Desired outcomes
Patient demonstrates deep breathing and effective coughing at least hourly and is
eupneic (respiratory rate [RR] 12-20 breaths/min with normal depth and pattern) at all
other times. Auscultation of patient's lungs reveals no adventitious sounds.
Nursing Interventions
Auscultate breath sounds at least q2-4h (or as indicated by patient's condition) and
during hyperinflation therapy. Report any decrease in breath sounds or presence
of/increase in adventitious breath sounds.
Instruct patient in use of hyperinflation device (e.g., incentive spirometer) to expand the
lungs maximally.
Deep breathing expands the alveoli and aids in mobilizing secretions to the airways,
and coughing further mobilizes and clears the secretions. Monitor patient's progress
and document in nurses' notes.
Administer analgesics as prescribed to reduce pain and thereby facilitate coughing and
deep-breathing exercises.
46
Instruct patients who are unable to cough effectively in technique of cascade cough (i.e.,
succession of short and more forceful exhalations).
Encourage frequent position changes and other activity as prescribed to help mobilize
secretions and promote effective airway clearance. Use upright sitting position if
permitted to promote good chest expansion.
When not contraindicated, instruct patient to increase fluid intake (to more than
2.5 L/day) to decrease viscosity of pulmonary secretions and facilitate their
mobilization.
47
Precipitating factors in the development of atelectasis.
Pneumonia
Overview/Pathophysiology
Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung
parenchyma (alveolar spaces and interstitial tissue). As a result of the inflammation,
involved lung tissue becomes edematous and air spaces fill with exudate (consolidation),
gas exchange cannot occur, and nonoxygenated blood is shunted into the vascular
system, with resulting hypoxemia. Bacterial pneumonias involve all or part of a lobe,
whereas viral pneumonias appear diffusely throughout the lungs.
Influenza, which can cause pneumonia, is the most serious viral airway infection for
adults. Patients more than 65 yr old, residents of extended care facilities, and
individuals with chronic health conditions have the highest mortality from influenza.
Pneumonias usually are classified into two general types: community acquired and
hospital associated (nosocomial). A third type now recognized is pneumonia in the
immunocompromised individual.
Community acquired
Individuals with community-acquired pneumonia, the most common type, generally do
not require hospitalization unless an underlying medical condition, such as chronic
obstructive pulmonary disease (COPD), cardiac disease, or diabetes mellitus, or an
immunocompromised state complicates the illness.
48
membrane is affected, acute respiratory distress syndrome (ARDS) (formerly known as
adult respiratory distress syndrome) may develop.
Assessment
Findings are influenced by patient's age, extent of the disease process, underlying
medical condition, and pathogen involved. Generally, any factor that alters integrity of
the lower airways, thereby inhibiting ciliary activity, increases the likelihood of
developing pneumonia ( TABLE 2-1 ).
TABLE 2-1
ASSESSMENT GUIDELINES BY PNEUMONIA TYPE
49
TYPE/PATHOGEN RISK ONSET DEFINING COMPLICATIONS/C
GROUPS CHARACTE OMMENTS
RISTICS
ileus
Mycoplasma School-aged Gradual Cough, sore Persistent cough
(Mycoplasma children to throat, fever, and sinusitis
pneumoniae) young adults headache, possible; pulse-
(5-30 yr); chills, temperature
intrafamilial malaise, dissociation
spread anorexia, common;
common nausea, Occurrence rare
vomiting,
diarrhea; in
children
arthralgias
involving
large joints
common
Legionnaires'(Legi Middle-aged, Abrupt Malaise, Respiratory failure,
onella elderly headache hypotension, shock,
pneumophila) populations within 24 hr, acute renal failure
(men at fever with
increased normal HR,
risk); shaking
smokers; chills,
individuals progressive
with dyspnea,
malignant cough that
disease, may become
immunosupp productive;
ression, or GI
chronic renal symptoms,
failure; including
exposure to anorexia,
contaminate vomiting,
d diarrhea;
construction arthralgias,
site myalgias
Viral influenza A Elderly 1 wk after Severe Rapid course
persons with onset of dyspnea; leading frequently to
chronic influenza cyanosis; acute respiratory
diseases symptoms scant failure; develops as
(e.g., COPD, sputum, secondary bacterial
50
TYPE/PATHOGEN RISK ONSET DEFINING COMPLICATIONS/C
GROUPS CHARACTE OMMENTS
RISTICS
diabetes occasionally pneumonia
mellitus, with blood;
heart failure); fever;
pregnant persistent
women and dry
cough
Haemophilus Adults 2-6 wk after Fever, chills, Fever may be
influenzae (especially URI dyspnea, minimal or absent;
50 yr of age cough, HR and RR may be
or older) with nausea, normal
chronic vomiting,
diseases pain
(e.g.,
diabetes
mellitus,
COPD,
chronic
alcohol
ingestion)
Nosocomial
Klebsiella Men older Abrupt Chills, fever, Lung abscess and
(Klebsiella than 40 yr, productive empyema,
pneumoniae); also alcoholic cough necrotizing
may be acquired in patients; (copious pneumonitis with
the community patients with purulent cavitation, acute
diabetes green or respiratory failure;
mellitus, currant jelly high mortality
COPD, or sputum), (greater than 50%);
heart severe aspiration of
disease; pleuritic oropharyngeal flora
those chest pain, is responsible for
previously dyspnea, both nosocomial and
treated with cyanosis, community-acquired
antibiotics or jaundice, cases
ET intubation vomiting,
diarrhea
Pseudomonas;also Patients who Gradual Fever, chills, Rare in previously
may be acquired in are confusion, healthy adults; high
the community neutropenic delirium, mortality
from bradycardia,
51
TYPE/PATHOGEN RISK ONSET DEFINING COMPLICATIONS/C
GROUPS CHARACTE OMMENTS
RISTICS
chemotherap purulent
y or sputum
immunosupp (green, foul
ressed smelling)
secondary to
cortisone
therapy or
other
illnesses
Proteus Older adults Abrupt High fever, Occurrence rare;
with chills, localizes to areas
debilitating pleuritic already damaged;
underlying chest pain occurs as a mixed
diseases infection; associated
with four pathogenic
species with differing
antibiotic
susceptibilities
Staphylococcus Patients with Abrupt with Cough, chills, Pulmonary
aureus debilitating community high fever, abscesses,
diseases acquired; pleuritic pain, empyema, pleural
(e.g., insidious with progressive effusions; slow
diabetes hospital dyspnea, response to
mellitus, associated cyanosis, antibiotics
renal failure, bloody
liver disease, sputum
COPD);
those with a
prior viral or
influenza
infection;
injecting drug
users
Aspiration of Patients with Gradual; Fever, Physiologic
gastric contents impaired latent period wheezes, response depends
gag/cough between crackles on pH contents of
reflexes; aspiration (rales), material aspirated:
general and onset of rhonchi, 2.5 or higher, little
anesthesia; symptoms dyspnea, necrosis occurs; less
presence of cyanosis than 2.5, atelectasis,
52
TYPE/PATHOGEN RISK ONSET DEFINING COMPLICATIONS/C
GROUPS CHARACTE OMMENTS
RISTICS
NG/ET tube pulmonary edema,
hemorrhage, and
necrosis can occur
Immunocompromised Patient
Pneumocystis (Pn Patients with Insidious Several Bronchoscopy with
eumocystis AIDS or weeks of transbronchial
jiroveci; formerly organ fever, biopsy usually
known as P. carinii) transplants nonproductiv required for
e cough, diagnosis
night sweats,
dyspnea;
hypoxemia
with few
auscultatory
signs
Aspergillosis(Aspe Patients with Abrupt with High fever; Cavitation frequent;
rgillus) AIDS, immunosupp fungal ball hematogenous
COPD, and ression; within lung spread common in
transplants insidious with cyst or cavity; immunocompromise
(especially COPD nonproductiv d patient
autologous e cough;
bone marrow pleuritic
transplant); chest pain
also those
receiving
cytotoxic
agents or
steroids
View full size
note: Enterobacter and Serratia are enteric organisms that cause pneumonia with the same clinical
pattern as Klebsiellaorganisms.
AIDS, Acquired immunodeficiency syndrome; COPD, chronic obstructive pulmonary
disease; ET, endotracheal; GI,gastrointestinal; HR, heart rate; NG, nasogastric; RR, respiratory
rate; URI, upper respiratory infection.
Signs and symptoms/physical findings
Cough (productive and nonproductive), increased sputum production (rust colored,
discolored, purulent, bloody, or mucoid), fever, pleuritic chest pain (more common in
community-acquired bacterial pneumonias), dyspnea, chills, headache, myalgia,
restlessness; anxiety; decreased skin turgor and dry mucous membranes secondary to
dehydration; presence of nasal flaring and expiratory grunt; use of accessory muscles of
53
respiration (scalene, sternocleidomastoid, external intercostals); decreased chest
expansion caused by pleuritic pain; dullness on percussion over affected (consolidated)
areas; tachypnea (respiratory rate [RR] more than 20 breaths/min); tachycardia (heart
rate [HR] more than 90 beats per minute [bpm]); increased vocal fremitus; egophony
(e to a change) over area of consolidation; decreased breath sounds; high-pitched
and inspiratory crackles (rales) (increased by or heard only after coughing); low-pitched
inspiratory crackles (rales) caused by airway secretions; and circumoral cyanosis (a late
finding). Older adults may be confused or disoriented and have low-grade fevers but
may present with few other signs and symptoms.
Diagnostic Tests
Chest x-ray examination
Confirms presence of pneumonia (i.e., infiltrate appearing on the film).
WBC count
Increased (more than 12,000/mm 3 ) in the presence of bacterial pneumonias. Normal or
low WBC (less than 4000/mm 3 ) count may be seen with viral or mycoplasma
pneumonias.
Chemistry panel
Detects presence of hypernatremia and/or hyperglycemia.
Oximetry
May reveal decreased O 2 saturation (92% or less).
54
Serologic studies
Acute and convalescent antibody titers drawn to diagnose viral pneumonia. A relative
rise in antibody titers suggests viral infection.
Collaborative Management
O therapy
2
Antibiotic agents
Prescribed empirically based on presenting signs and symptoms, clinical findings, and
chest x-ray results until sputum or blood culture results are available. Many organisms
responsible for nosocomial pneumonias are resistant to multiple antibiotics. Proper
identification of the organism and determination of sensitivity to specific antibiotics are
critical for determining appropriate therapy.
Hydration
IV fluids may be necessary to replace fluids lost from insensible sources (e.g., tachypnea,
diaphoresis, fever) and decreased oral intake.
55
Hyperinflation therapy
Prescribed for patients with inadequate inspiratory effort. (See p. 58 )
Antitussives
Given in the absence of sputum production if coughing is continuous and exhausting to
the patient.
Vaccines
Pneumococcal vaccine
Administered to patients who have chronic health conditions and to those who are more
than 65 yr old and/or are residents of an extended care facility and who have not
received the vaccine within the last 5 yr. Vaccine history should be assessed on
admission, and vaccine should be given to patients who meet criteria without
contraindications (allergy).
Influenza vaccine
Administered to patients with chronic health conditions and to those who are more than
50 yr old and/or are residents of an extended care facility and who have not received the
vaccine within the year. Influenza vaccines are routinely administered from October
through March. Vaccine history should be assessed on admission, and vaccine should be
given to patients who meet criteria without contraindications (e.g., allergy, history of
Guillain-Barr syndrome).
Infection control
See discussion in Appendix 1 , p. 743 .
Desired outcomes
Hospital discharge based on patient exhibiting at least five of the following indicators:
temperature 37.8 C or less, HR 100 bpm or less, RR 24 breaths/min or less, SBP
90 mm Hg or more, O 2 saturation 90% or more, and ability to maintain oral intake.
Nursing Interventions
56
Observe for restlessness, anxiety, mental status changes, shortness of breath, tachypnea,
and use of accessory muscles of respiration, all of which are indicators of respiratory
distress . Remember that cyanosis of the lips and nail beds may be a late indicator of
hypoxia.
Monitor and document VS q2-4h. Be alert to a rising temperature and other changes in
VS that may indicate infection (e.g., increased HR, increased RR).
Monitor oximetry readings; report O 2 saturation 92% or less because this can indicate a
need for O 2therapy.
Facilitate coordination among health care providers to provide rest periods between
care activities to decrease O 2 demand . Allow 90 min for undisturbed rest.
57
Ineffective airway clearance
related to presence of tracheobronchial secretions secondary to infection or related to
pain and fatigue secondary to lung consolidation
Desired outcomes
Patient demonstrates effective cough. Following intervention, patient's airway is free of
adventitious breath sounds.
Nursing Interventions
Maintain a patent airway and ensure that secretions are removed. Suction as
indicated/prescribed.
Auscultate breath sounds q2-4h (or as indicated by patient's condition), and report
changes in patient's ability to clear pulmonary secretions.
Inspect sputum for quantity, odor, color, and consistency; document findings. As
patient's condition worsens, sputum can change in color from clear white yellow
green, or it may show other discoloration characteristic of underlying bacterial infection
(e.g., rust colored, currant jelly).
Ensure that patient performs deep-breathing with coughing exercises at least q2h. Assist
patient into position of comfort, usually semi-Fowler's position, to facilitate
effectiveness and ease of these exercises.
Assess need for hyperinflation therapy (i.e., patient's inability to take deep breaths).
Report complications of hyperinflation therapy to health care provider, including
hyperventilation, gastric distention, headache, hypotension, and signs and symptoms of
pneumothorax (shortness of breath, sharp chest pain, unilateral diminished breath
sounds, dyspnea, cough).
Teach patient to splint chest with pillow, folded blanket, or crossed arms when
coughing, to reduce pain.
58
Ensure that patient receives prescribed chest physiotherapy. Document patient's
response to treatment.
Assist patient with position changes q2h to help mobilize secretions. If the patient is
ambulatory, encourage ambulation to patient's tolerance.
When not contraindicated, encourage fluid intake (2.5 L/day or more) to decrease
sputum viscosity.
Desired outcomes
At least 24 hr before hospital discharge, patient is normovolemic as evidenced by urine
output 30 mL/hr or more, stable weight, HR less than 100 bpm, SBP greater than
90 mm Hg, fluid intake approximating fluid output, moist mucous membranes, and
normal skin turgor.
Nursing Interventions
Weigh patient daily at the same time of day and on the same scale; record weight.
Report weight decreases of 1-1.5 kg/day.
Encourage fluid intake (at least 2.5 L/day in the unrestricted patient) to ensure
adequate hydration.
59
Promote oral hygiene, including lip and tongue care, to moisten dried tissues and
mucous membranes.
Desired outcome
Patient is free of infection as evidenced by normothermia, WBC count 12,000/mm 3 or
less, and sputum clear to whitish.
Nursing Interventions
Perform good handwashing technique before and after contact with patient (even
though gloves are worn).
Advise patients who smoke to discontinue smoking, especially during preoperative and
postoperative periods. Refer to a community-based smoking cessation program as
60
needed. When appropriate, discuss possibility of health care provider's prescription of
transdermal nicotine patches to facilitate smoking cessation.
Identify patients who are at increased risk for aspiration: individuals with depressed
LOC, dysphagia, or nasogastric (NG) or enteral tube in place. Maintain head of bead
(HOB) at 30-45-degree elevation, and turn patient onto side rather than back. When
patient receives enteral alimentation, recommend continuous rather than bolus
feedings. Hold feedings when patient is lying flat.
Recognize risk factors for patients with tracheostomy: presence of underlying lung
disease or other serious illness, increased colonization of oropharynx or trachea by
aerobic gram-negative bacteria, greater access of bacteria to lower respiratory tract, and
cross-contamination caused by manipulation of tracheostomy tube.
Wear gloves on both hands until tracheostomy wound has healed or formed granulation
tissue around the tube or when handling mechanical ventilation tubing.
Suction prn rather than on a routine basis because frequent suctioning increases risk of
trauma and cross-contamination.
Use sterile catheter for each suctioning procedure. Consider use of closed suction
system to further minimize risk of contamination ; replace closed suction system if
soiled, for mechanical failure, or per agency policy. Always avoid reusing a suction
system for subsequent patients. Avoid saline instillation during suctioning. If patient
has tenacious secretions, increase heat and humidity to loosen them.
61
Recognize the ways in which nebulizer reservoirs can contaminate patient: introduction
of nonsterile fluids or air, manipulation of nebulizer cup, or backflow of condensate
from delivery tubing into reservoir or into patient when tubing is manipulated.
Use only sterile fluids and dispense them using sterile technique.
Replace (rather than replenish) solutions and equipment at frequent intervals. For
example, empty reservoir completely and refill with sterile solution q8-24h, per agency
protocol.
Change breathing circuits every week unless circuits are soiled, mechanical failure
occurs, or agency policy states otherwise.
Discard any fluid that has condensed in tubing; do not allow fluid to drain back into
reservoir or into patient.
62
Signs and symptoms of pneumonia and importance of reporting them promptly if they
recur. Teach patient's significant others that changes in mental status may be the only
indicator of pneumonia if patient is elderly.
Importance of preventing fatigue by pacing activities and allowing frequent rest periods.
Minimizing factors that can cause reinfection, including close living conditions, poor
nutrition, and poorly ventilated living quarters or work environment.
Phone numbers to call if questions or concerns arise about therapy or disease after
discharge. Additional general information can be obtained from the American Lung
Association at www.lungusa.org .
Information about the free brochures that discuss ways to stop smoking such as the
following:
Pleural Effusion
Overview/Pathophysiology
A pleural effusion is an accumulation of fluid (blood, pus, chyle, serous fluid) in the
pleural space. Generally, fluid gravitates to the most dependent area of the thorax, and
the adjacent lung becomes compressed. Pleural effusion is rarely a disease in itself, but
rather it is caused by a number of inflammatory, circulatory, or neoplastic diseases.
Transudate effusion results from changes in hydrodynamic forces in the circulation and
63
usually is caused by heart failure (increased hydrostatic pressure) or cirrhosis
(decreased colloidal osmotic pressure). Exudate effusion results from irritation of the
pleural membranes secondary to inflammatory, infective, or malignant processes. More
exact nomenclature can be used once the nature of the fluid in the pleural effusion has
been identified, that is, hydrothorax (a transudate or exudate of serous fluid), pyothorax
or empyema (collection of purulent material), hemothorax (bloody fluid), or chylothorax
(effused chyle).
Assessment
Clinical indicators of pleural effusion are related to the underlying disease. Patients with
a small effusion (less than 300 mL) may be asymptomatic.
Diagnostic Tests
Chest x-ray examination
Shows evidence of effusion if more than 300 mL of fluid is in the pleural space. With
effusion greater than 1000 mL, the x-ray film may show mediastinal shift away from the
affected lung.
Thoracentesis
Removal of fluid from the pleural space for examination to provide definitive diagnosis
and determine type of effusion.
Collaborative Management
Therapeutic thoracentesis
Removes fluid and thereby allows lung to reexpand. Rate of recurrence and time span
for return of symptoms are recorded.
Sclerosing pleurodesis
Produces pleural fibrosis and symphysis (line of fusion between visceral and parietal
pleural layers) by instillation of sclerosing agent (tetracycline, bleomycin, or nitrogen
mustard) via chest tube.
Desired outcome
Following intervention, patient's breathing pattern moves toward eupnea.
Nursing Interventions
Auscultate breath sounds q2-4h (or as indicated by patient's condition), and monitor for
decreasing breath sounds or presence of pleural friction rub.
Monitor oximetry readings; report O 2 saturation 92% or less because this can indicate
need for O 2therapy .
If hyperinflation therapy is prescribed, instruct patient in its use and document patient's
progress.
For patients with gross pleural effusion, provide the following instructions for apical
expansion breathing exercise:
65
o
Sit upright.
Inhale and attempt to push upper chest wall against pressure of the fingers.
When performed at frequent intervals, this exercise will help expand the involved lung
tissues, minimize flattening of the upper chest, and mobilize secretions.
66
Pulmonary Embolism
Overview/Pathophysiology
The most common pulmonary perfusion abnormality is pulmonary embolism (PE). PE
is caused by passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into
the pulmonary artery or its branches, with resulting obstruction of the blood supply to
lung tissue and subsequent collapse. The most common source is a dislodged blood clot
from the systemic circulation, typically the deep veins of the legs or pelvis. Thrombus
formation is the result of the following factors: blood stasis, alterations in clotting
factors, and injury to vessel walls. A fat embolus is the most common nonthrombotic
cause of pulmonary perfusion disorders (see p. 74 ).
Assessment
Signs and symptoms/physical findings
Often nonspecific and variable, depending on extent of obstruction and whether patient
has infarction as a result of the obstruction.
Sudden onset of dyspnea and sharp chest pain, restlessness, anxiety, nonproductive
cough or hemoptysis, palpitations, nausea, syncope, tachypnea, tachycardia,
hypotension, crackles (rales), decreased chest wall excursion secondary to splinting,
S 3 and S 4 gallop rhythms, transient pleural friction rub, jugular venous distention,
diaphoresis, edema, and cyanosis.
If infarction has occurred, fever, pleuritic chest pain, and hemoptysis are common.
Cardiac disorders
Atrial fibrillation, heart failure, myocardial infarction, rheumatic heart disease.
Surgery
Risk increases in postoperative period, especially for patients with orthopedic, pelvic,
thoracic, or abdominal surgery and for those with extensive burns or musculoskeletal
injuries of the hip or knee.
67
Pregnancy
Especially during postpartum period.
Mechanical ventilation
Risk increases because of immobility and inflammatory processes.
Carcinoma
Particularly neoplasms involving the breast, lung, pancreas, and genitourinary and
alimentary tracts.
Obesity
A 20% increase in ideal body weight is associated with increased incidence of PE.
Diagnostic Tests
Arterial blood gas (ABG) values
Hypoxemia (Pa o 2 less than 80 mm Hg), hypocarbia (Pa co 2 less than 35 mm Hg), and
respiratory alkalosis (pH more than 7.45) usually are present. Normal values do not rule
out PE.
D-dimer
A degradation product produced by plasmin-mediated proteolysis of cross-linked fibrin
and measured by enzyme-linked immunosorbent assay (ELISA). The higher the result
(with less than 250 ng/mL considered negative in most laboratories), the more likely it
is patient has PE. This test is not sensitive or specific enough to diagnose PE, but it may
be used in conjunction with other diagnostic tests.
68
from the decrease in surfactant. If pulmonary infarction is present, infiltrates and
pleural effusions may be seen within 12-36 hr.
ECG results
Abnormal in 85% of patients with PE.
Pulmonary angiography
Definitive study for PE: An invasive procedure that involves catheterization of right side
of the heart and injection of dye into the PA to visualize pulmonary vessels. Abrupt
vessel cutoff may be seen at the site of embolization. Usually, filling defects are seen.
More specific findings are abnormal blood vessel diameters (i.e., obstruction of right PA
would cause dilation of left PA) and abnormal blood vessel shapes (i.e., affected blood
vessel may taper to a sharp point and disappear).
Collaborative Management
The three goals of therapy are (1) prophylaxis for individuals at risk for development of
PE, (2) treatment during acute embolic event, and (3) prevention of future embolic
events in individuals who have experienced PE.
O therapy
2
Anticoagulation
Low molecular weight heparin (LMWH) or unfractionated heparin (UFH)
therapy
Started immediately in patients without bleeding or clotting disorders and in whom PE
is strongly suspected with the aim of inhibiting further thrombus growth, promoting
resolution of the formed thrombus, and preventing further embolus formation.
Continued for at least 5 days to allow for depletion of thrombin.
LMWH
69
Preferred to UFH because of more predictable dosing, fewer side effects, once- or twice-
daily subcutaneous administration, and lack of need to monitor activated partial
thromboplastin time. Dose is weight based and differs for various LMWH preparations.
Dose must be adjusted for individuals with renal impairment because most LMWH is
excreted by the kidneys. LMWH has been shown to be safe if given during pregnancy.
UFH
Has shorter half-life than LMWH and effect is completely reversible with protamine.
Ideally, dosage is weight based (e.g., IV bolus of 80 units/kg followed by a maintenance
dose of 18 units/kg/hr). Alternatively, an initial IV bolus of 5000-10,000 units followed
by continuous infusion of 1000 units/hr may be given. Effect is monitored by activated
partial thromboplastin time (aPTT) measurements every 6 hr after initial dose until the
goal of 1.5 to 2.5 control value is consistently established.
Reverses effects of warfarin in 24-36 hr. Fresh frozen plasma may be required in cases
of serious bleeding. Warfarin crosses the placental barrier and can cause spontaneous
abortion and birth defects.
Thrombolytic therapy
May be given in the first 24-48 hr after diagnosis of PE to speed the process of clot lysis
via conversion of plasminogen to plasmin. Thrombolytic therapy may be preferred for
initial treatment of PE in patients with hemodynamic compromise, with greater than
30% occlusion of pulmonary vasculature, and in whom therapy has been initiated no
later than 3 days after onset of PE. Thrombin time is measured q4h during therapy to
ensure adequate response, which should be 2-5 normal. Partial thromboplastin time
(PTT) can be used instead of thrombin time and should be 2-5 control. Once
thrombolytic therapy is stopped, thrombin time or PTT should be checked frequently
until values fall to less than 2 normal. When this occurs, heparin therapy is started
and continued as described earlier. As many as 33% of patients receiving thrombolytic
therapy have hemorrhagic complications.
70
110 mm Hg or SBP higher than 185 mm Hg), pregnancy, and status less than 10 days
post partum.
Surgical interventions
Used only in select cases because anticoagulant therapy is usually successful.
Pulmonary Embolectomy
Removes clots from the pulmonary circulation. Generally, use of thrombolytic agents
eliminates need for this procedure.
Desired outcomes
Following intervention/treatment, patient exhibits adequate gas exchange and
ventilatory function as evidenced by respiratory rate (RR) of 12-20 breaths/min with
normal pattern and depth (eupnea); no significant changes in mental status; and
orientation to person, place, and time. At least 24 hr before hospital discharge, patient
has O 2saturation greater than 90% or Pa o 2 80 mm Hg or higher, Pa co 2 35-45 mm Hg,
and pH 7.35-7.45 (or values consistent with patient's acceptable baseline parameters).
Nursing Interventions
Monitor for signs and symptoms of increasing respiratory distress: RR increased from
baseline; increasing dyspnea, anxiety, restlessness, confusion, and cyanosis.
As indicated, monitor oximetry readings; report O 2 saturation 90% or less because this
can indicate need for O 2 therapy.
Position patient for comfort and optimal gas exchange. Ensure that area of the lung
affected by embolus is not dependent when patient is in lateral decubitus position.
Elevate head of bed (HOB) 30 degrees to improve ventilation .
71
Avoid positioning patient with knees bent (i.e., gatching bed) because this impedes
venous return from legs and can increase risk of PE. Instruct patient not to cross legs
when lying in bed or sitting in a chair.
Limit or pace patient's activities and procedures to decrease metabolic demands for O 2 .
Ensure that patient performs deep-breathing and coughing exercises 3-5 q2h to
maximize ventilation.
Monitor serial ABG values and assess for desired response to treatment. Report lack of
response to treatment or worsening ABG values.
Ineffective protection
related to risk of prolonged bleeding or hemorrhage secondary to anticoagulation
therapy
Desired outcomes
Patient is free of frank or occult bleeding; body secretions/excretions test negative for
blood.
Nursing Interventions
At least once each shift inspect wounds, oral mucous membranes, any entry site of an
invasive procedure, and nares for evidence of bleeding.
At least once each shift inspect torso and extremities for petechiae or ecchymoses.
72
Apply pressure to all venipuncture or arterial puncture sites until bleeding stops
completely.
If patient is receiving heparin therapy, monitor serial aPTT (desired range is 1.5-2.5
control). If patient is receiving warfarin therapy, monitor serial PT (desired range is
1.25-1.5 control, or INR value of 2.0-3.0). Report values outside desired range.
73
Warfarin sodium: Numerous drugs decrease or increase response to treatment with
warfarin. Consult pharmacist to obtain specific information about patient's medication
profile. Antibiotics routinely increase INR levels, check with the pharmacist for drug
interactions.
Discuss with patient and significant others the importance of reporting promptly the
presence of bleeding from any of the following sources: hematuria, melena, frank
bleeding from the mouth, epistaxis, hemoptysis, excessive vaginal bleeding
(menometrorrhagia).
Teach necessity of using sponge-tipped applicators and mouthwash for oral care to
minimize risk of gum bleeding. Instruct patient to shave with electric rather than
straight or safety razor.
If patient is restless and combative, provide a safe environment. Use extreme care when
moving patient to avoid bumping patient's extremities into side rails and causing
bleeding.
Deficient knowledge
related to oral anticoagulant therapy, potential side effects, and foods and medications
to avoid during therapy
Desired outcome
Before hospital discharge, patient verbalizes knowledge of prescribed anticoagulant
drug, potential side effects, and foods and medications to avoid while receiving oral
anticoagulant therapy.
Nursing Interventions
74
Assess patient's facility with language; engage an interpreter or language-appropriate
written materials if necessary.
Discuss importance of laboratory testing and follow-up visits with health care provider.
Explain importance of informing all health care providers (including dentist) that
patient is taking an anticoagulant. Suggest that patient wear a MedicAlert tag or
otherwise carry identification to alert health care providers about the anticoagulant
therapy.
Teach patient to notify doctor if diet contains large amounts of foods high in vitamin K
(e.g., fish, bananas, dark-green vegetables, tomatoes, cauliflower), which can interfere
with anticoagulation .
Caution patient that soft-bristled rather than hard-bristled toothbrush and electric
rather than straight or safety razor should be used during anticoagulant therapy to
minimize risk of injury that could cause bleeding.
Instruct patient to consult health care provider before taking over-the-counter (OTC) or
prescribed drugs that were used before initiating anticoagulant therapy. Aspirin,
cimetidine, trimethaphan, and macrolides are among the many drugs that enhance
response to warfarin. Drugs that decrease response include antacids, diuretics, oral
contraceptives, and barbiturates.
75
Reinforce patient teaching about oral anticoagulant therapy (see Deficient knowledge ).
Also provide verbal and written information about the following:
Signs and symptoms of PE: sudden onset of dyspnea, anxiety, nonproductive cough or
hemoptysis, palpitations, nausea, syncope.
Fat Embolism
Fat embolism is the most common type of nonthrombotic PE. Free fatty acids cause
toxic vasculitis, followed by thrombosis and obstruction of small pulmonary arteries by
fat.
Assessment
Signs and symptoms/physical findings
Typically, patient is asymptomatic for 12-24 hr following embolization. This period ends
with sudden cardiopulmonary and neurologic deterioration: apprehension, restlessness,
mental status changes, confusion, delirium, coma, dyspnea, tachypnea, tachycardia, and
hypertension; fever; petechiae, especially of conjunctivae, neck, upper torso, axillae, and
proximal arms; inspiratory crowing; pulmonary edema; profuse tracheobronchial
secretions; fat globules in sputum; and expiratory wheezes.
Diagnostic Tests
ABG values
76
Should be determined in patients at risk for fat embolus for the first 48 hr following
injury because early hypoxemia indicative of fat embolus is apparent only with
laboratory assessment. Hypoxemia (Pa o 2 less than 80 mm Hg) and hypercarbia
(Pa co 2 more than 45 mm Hg) are present with respiratory acidosis (pH less than 7.35).
Serum lipase
Value rises with fat embolism.
Urinalysis
May reveal fat globules following fat embolus.
Collaborative Management
O 2
Diuretics
Approximately 30% of patients with fat emboli develop pulmonary edema that
necessitates use of diuretics.
Pneumothorax/Hemothorax
Overview/Pathophysiology of Pneumothorax
Pneumothorax is an accumulation of air in the pleural space that leads to increased
intrapleural pressure. Risk factors include blunt or penetrating chest injury, chronic
obstructive pulmonary disease (COPD), previous pneumothorax, and positive-pressure
ventilation. The three types of pneumothorax are as follows:
Spontaneous
Also referred to as closed pneumothorax because the chest wall remains intact with no
leak to the atmosphere. It results from rupture of a bleb or bulla on the visceral pleural
77
surface, usually near the apex. Generally, the cause of the rupture is unknown, although
it may result from a weakness related to a respiratory infection or from an underlying
pulmonary disease (e.g., COPD, tuberculosis (TB), malignant neoplasm). The affected
individual is usually young (20-40 yr), previously healthy, and male. Onset of symptoms
usually occurs at rest rather than with vigorous exercise or coughing. Potential for
recurrence is great; the second pneumothorax occurs an average of 2-3 yr after the first.
Traumatic
Can be open or closed. An open pneumothorax occurs when air enters the pleural space
from the atmosphere through an opening in the chest wall, such as with a gunshot
wound, stab wound, or invasive medical procedure (e.g., thoracentesis or placement of a
central line into a subclavian vein). A sucking sound may be heard over the area of
penetration during inspiration, a feature that accounts for the classic wound description
as a sucking chest wound. A closed traumatic pneumothorax occurs when the visceral
pleura is penetrated but the chest wall remains intact with no atmospheric leak. This
usually occurs following blunt trauma that results in rib fracture and dislocation. It also
may occur from use of positive end-expiratory pressure (PEEP) or after
cardiopulmonary resuscitation (CPR).
Tension
Generally occurs with closed pneumothorax; also can occur with open pneumothorax
when a flap of tissue acts as a one-way valve. Air enters the pleural space through the
pleural tear when the individual inhales, and it continues to accumulate but cannot
escape during expiration because the tissue flap closes. With tension pneumothorax, as
pressure in the thorax and mediastinum increases, it produces a shift in the affected
lung and mediastinum toward the unaffected side that further impairs ventilatory
efforts. The increase in pressure also compresses the vena cava. This compression
impedes venous return and leads to a decrease in cardiac output and ultimately to
circulatory collapse if the condition is not diagnosed and treated quickly. Tension
pneumothorax is a life-threatening medical emergency.
Overview/pathophysiology of hemothorax
Hemothorax is an accumulation of blood in the pleural space. Hemothorax generally
results from blunt trauma to the chest wall, but it also can occur following thoracic
surgery, after penetrating gunshot or stab wounds, as a result of anticoagulant therapy,
after insertion of a central venous catheter, or following various thoracoabdominal
organ biopsies. Mediastinal shift, ventilatory compromise, and lung collapse can occur,
depending on the amount of blood accumulated.
Assessment
Signs and symptoms/physical findings vary, depending on type and size of the
pneumothorax or hemothorax (TABLE 2-2 ).
TABLE 2-2
SIGNS AND SYMPTOMS/PHYSICAL FINDINGS WITH PNEUMOTHORAX OR HEMOTHORAX
78
SPONTANEOUS OR TRAUMATIC
PNEUMOTHORAX
CLOSED OPEN TENSION HEMOTHORAX
PNEUMOTHORAX
Signs and Symptoms
Shortness of breath, Shortness of Dyspnea, chest pain Dyspnea, chest
cough, chest breath, sharp chest pain
tightness, chest pain pain
Physical Assessment
Tachypnea, Agitation, Anxiety, tachycardia, Tachypnea, pallor,
decreased thoracic restlessness, cyanosis, jugular vein cyanosis, dullness
movement, tachypnea, distention, tracheal over affected side,
cyanosis, cyanosis, presence deviation toward the tachycardia,
subcutaneous of chest wound, unaffected side, hypotension,
emphysema, hyperresonance absent breath sounds diminished or
hyperresonance over affected area, on affected side, absent breath
over affected area, sucking sound on distant heart sounds, sounds, change
diminished breath inspiration, hypotension, change mental status
sounds, paradoxical diminished breath in mental status
movement of chest sounds, change in
wall (may signal flail mental status
chest), change in
mental status
View full size
Diagnostic Tests
Chest x-ray examination
Reveals presence of air or blood in the pleural space on the affected side,
pneumothorax/hemothorax size, and any shift in the trachea and mediastinum.
Oximetry
Reveals decreased O 2 saturation (90% or less).
CBC
May reveal decreased Hgb proportionate to amount of blood lost in the hemothorax.
79
Collaborative Management
Management is determined by signs and symptoms. A small pneumothorax (less than
20%) may heal itself via reabsorption of the free air and may thereby render invasive
procedures unnecessary unless an underlying disease process or injury is present.
Hemothorax nearly always requires intervention.
O therapy
2
Thoracentesis/air aspiration
Used for hemothorax to remove blood from the pleural space. For cases of tension
pneumothorax, thoracentesis/air aspiration is performed immediately to remove air
from the pleural space. A large-bore needle is inserted in the second intercostal space,
midclavicular line, which correlates to the superior portion of the anterior axillary lobe.
A sudden rushing out of air confirms the diagnosis of tension pneumothorax. Following
release of entrapped air, chest tubes are inserted. Air aspiration may be done when a
pneumothorax is large enough to allow lung reexpansion; if only partial reexpansion
occurs, a one-way valve may be attached to the thoracentesis catheter to allow for
outpatient management.
Thoracotomy
Often indicated in patients who have had two or more spontaneous pneumothoraces on
one side because of risk of continuous recurrence or if pneumothorax does not resolve
within 7 days. With hemothorax, thoracotomy is performed to locate the source and
control bleeding if blood loss is excessive. Thoracotomy may include mechanical
abrasion of the pleural surfaces with a dry sterile sponge or chemical abrasion via an
agent such as tetracycline solution or talc, which results in pleural adhesions
(pleurodesis) that help prevent recurrence of pneumothorax. Partial pleurectomy may
be performed instead of mechanical or chemical abrasion.
80
Video-assisted thoracic surgery (VATS)
Performed in the operating room while patient is under general anesthesia. A small
thoracoscope is inserted through a small chest incision. Pleural fluid is removed and
pleural biopsy samples may be obtained. A chest tube is inserted and connected to
suction for further drainage.
Chemical pleurodesis
Instillation of a sclerosing agent (e.g., tetracycline, talc) into the pleural cavity to
produce adhesions and a line of fusion between visceral and parietal pleural layers.
IV therapy
Administered if significant loss of fluids or blood occurs.
Analgesia
Because of rich innervation of the pleura, chest tube placement or pleurodesis is painful,
and significant analgesia is usually required.
Desired outcomes
Following treatment/intervention, patient exhibits adequate gas exchange and
ventilatory function as evidenced by respiratory rate (RR) 20 breaths/min or less with
normal depth and pattern (eupnea); no significant mental status changes; and
orientation to person, place, and time. At a minimum of 24 hr before hospital discharge,
patient's ABG values are as follows: Pa o 2 80 mm Hg or more and Pa co 2 35-45 mm Hg
(or values within patient's acceptable baseline parameters), or oximetry readings
demonstrate O 2 saturation greater than 90%.
Nursing Interventions
Monitor serial ABG results to detect decreasing Pa o 2 and increasing Pa co 2 , which can
signal impending respiratory compromise , or monitor oximetry readings for
O 2 saturation 90% or less. Report significant findings.
Observe for increased restlessness, anxiety, tachycardia, and changes in mental status.
Cyanosis may be a late sign. These signs indicate hypoxia.
81
Assess VS and breath sounds q2h or as indicated by patient's condition.
Following tube or exploratory thoracotomy, check q15min until stable for increased RR,
diminished or absent movement of chest wall on affected side, paradoxical movement of
the chest wall, increased work of breathing (WOB), use of accessory muscles of
respiration, complaints of increased dyspnea, unilateral diminished breath sounds, and
cyanosis, which indicates respiratory distress. Evaluate heart rate (HR) and BP for
indications of shock (i.e., tachycardia and hypotension).
Position patient to allow for full expansion of unaffected lung. Semi-Fowler's position
usually provides comfort and allows adequate expansion of chest wall and descent of
diaphragm.
Change patient's position q2h to promote drainage and lung reexpansion and facilitate
alveolar perfusion.
Encourage patient to take deep breaths and provide necessary analgesia to decrease
discomfort during deep-breathing exercises . Instruct patient in splinting thoracotomy
site with arms, pillow, or folded blanket. Deep breathing promotes full lung expansion
and decreases risk of atelectasis. Coughingfacilitates mobilization of tracheobronchial
secretions, if present.
Desired outcome
Following intervention, patient becomes eupneic.
Nursing Interventions
82
sounds; be alert for and report signs of respiratory distress, including tachycardia,
restlessness, anxiety, and changes in mental status.
Tape all connections and secure chest tube to thorax with tape. Avoid all tubing kinks,
and ensure that the bed and equipment are not compressing any component of the
system.
Eliminate all dependent loops in tubing. These may impede removal of air and fluid
from the pleural space.
Be aware that the suction apparatus does not regulate amount of suction applied to
closed chest-drainage system. The amount of suction is determined by water level in the
suction control chamber. Minimal bubbling in this chamber is acceptable and desirable.
Dial the level of dry suction per health care provider's recommendation. Suction aids in
lung reexpansion, but removing suction for short periods, such as for transporting, will
not be detrimental or disrupt the closed chest-drainage system.
Avoid stripping of chest tubes. This mechanism for maintaining chest-tube patency is
controversial and has been associated with creating high negative pressures in the
pleural space, which can damage fragile lung tissue. Squeezing alternately hand over
hand along the drainage tube may generate sufficient pressure to move fluid along the
tube. Use of mechanical or handheld tube-stripping devices should be avoided.
83
Bubbling in the underwater-seal chamber occurs on expiration and is a sign that air is
leaving the pleural space. Continuous bubbling in the underwater-seal chamber may be
a signal that air is leaking into the drainage system. Locate and seal the system's air leak,
if possible.
Petrolatum gauze pad to apply over insertion site if the chest tube becomes dislodged ;
use of this dressing provides an airtight seal to prevent recurrent pneumothorax.
Bottle of sterile water in which to submerge the chest tube if it becomes disconnected
from the underwater-seal system.
Never clamp a chest tube without a specific directive from health care provider;
clamping may lead to tension pneumothorax because air in the pleural space no longer
can escape.
Acute pain
related to impaired pleural integrity, inflammation, or presence of a chest tube
Desired outcomes
Within 1 hr of intervention, patient's subjective perception of pain decreases, as
documented by pain scale. Objective indicators, such as grimacing, are absent or
diminished.
Nursing Interventions
Medicate with analgesics as prescribed and use pain scale to evaluate and document
medication effectiveness . Encourage patient to request analgesic before pain becomes
severe.
84
Facilitate coordination among health care providers to provide rest periods between
care activities to decrease O 2 demand . Allow 90 min for undisturbed rest.
Stabilize chest tube to reduce pull or drag on latex connector tubing. Tape chest tube
securely to thorax. Position tube to ensure there are no dependent loops.
Pulmonary Tuberculosis
Overview/Pathophysiology
85
Tuberculosis (TB) is an infectious disease caused primarily by Mycobacterium
tuberculosis. In the United States an estimated 10 to 15 million persons are infected
with this organism, most of whom have latent TB infection (LTBI) in which the bacteria
are in the body (usually the lungs) in a dormant form that neither causes disease nor is
communicable to other persons. A small proportion of persons (about 10%) with LTBI
will develop active TB in their lifetimes.
For many years (from 1953 to 1984), reported cases of TB in the United States decreased
by almost 6% each year, and the general perception was that TB was no longer a
problem. This decline was due to many factors, including improved living conditions
(less crowding and better ventilation), better nutrition, and antituberculosis drugs. As a
result, the public health infrastructure to support TB control weakened as other
diseases, for example, human immunodeficiency virus (HIV)/acquired
immunodeficiency syndrome (HIV/AIDS), became more prominent. It was not until the
late 1980s that a link between TB and HIV/AIDS became apparent, as was manifested
partly by multidrug-resistant (MDR) TB outbreaks occurring in seven hospitals between
1990 and 1992 and resulting in many cases of LTBI, TB disease, and death. In addition,
reported cases of TB increased 20% between 1985 and 1992. After the hospital
outbreaks and other changes in administrative and legislative support to control TB,
cases have steadily declined again in most areas of the country. In 2003, fewer than
15,000 cases of TB were reported in the United States, more than half of which were
among foreign-born persons. Worldwide, TB remains a leading cause of death in
developing countries; the World Health Organization (WHO) estimates that
approximately one third of the world's population is infected with M. tuberculosis.
M. tuberculosis is transmitted by the airborne route via minute, invisible particles called
droplet nuclei. When individuals with TB disease of the lungs or throat cough, sneeze,
speak, or sing, TB organisms harboring in their respiratory secretions are expelled into
the air and transform quickly into tiny droplet nuclei that can remain suspended in air
for several hours, depending on the environment (especially within ventilation systems).
To become infected, another person must breathe the air containing the droplet nuclei.
A person's natural defenses of the nose and upper airway and immune system often
prevent sufficient numbers of organisms from reaching the alveoli to cause infection. It
generally takes 5 to 200 bacilli implanted in the alveoli to cause LTBI. When bacilli
reach the alveoli, these organisms are ingested by macrophages. Some of these bacilli
spread through the bloodstream when the macrophages die; however, the immune
system response usually prevents the individual from developing TB disease. Although
most TB cases are pulmonary (85%), TB can occur in almost any part of the body or as
disseminated disease. About half the people with LTBI who develop active TB (5%) will
do so within the first year or two after infection. The remainder (5%) will develop active
TB within their lifetimes.
Close contacts of patients require identification so that they can undergo evaluation for
the presence of LTBI. TB is reportable to the public health department.
Assessment
86
For an accurate diagnosis of TB, a complete medical and psychosocial history is needed
along with a physical examination that includes a tuberculin skin test [TST], chest x-ray
examination, and sputum examination (including acid-fast bacillus [AFB] smears,
cultures, and drug sensitivity studies).
Diagnostic Tests
Sputum culture
Three sputum cultures are obtained 8 to 24 hr apart and are sent for AFB smear and
culture to ascertain presence of M. tuberculosis. Results of sputum culture are negative
in persons with LTBI.
Acid-fast stain
Detection of AFB in stained smears examined under a microscope usually provides the
first bacteriologic clue of TB. Smear results should be available within 24 hr of specimen
collection. AFB in the smear may be mycobacteria other than M. tuberculosis; many
patients can have TB and still have a negative smear. Specimens are generally collected
by asking patient to expectorate sputum into a cup; however, tracheal washing,
thoracentesis of pleural fluid, and lung biopsy are other options.
87
categories such as HIV-infected and recently HIV-exposed patients are considered
positive with 5 mm or greater induration. Those who are immunocompromised and
some patients with active TB may have a negative PPD test, even in the presence of
active TB disease. A positive PPD test indicates LTBI and is not diagnostic for active
disease.
Collaborative Management
Common drug regimens for treatment of LTBI
For persons suspected of having LTBI, treatment should not begin until active TB
disease has been excluded. The standard regimen (American Thoracic Society/Centers
for Disease Control and Prevention [ATS/CDC]) for LTBI treatment is 6 to 9 mo of
isoniazid (INH) or 4 mo of rifampin. Although these regimens are broadly applicable,
modifications should be considered under special circumstances that include HIV
infection, suspected drug resistance, pregnancy, and liver problems. Adequate LTBI
treatment reduces risk for development of active TB by about 70% (i.e., from a lifetime
risk of 10% to 3%).
88
Patient is placed in an airborne-infection isolation (AII) room until antimicrobial
therapy is successful and patient is determined to be no longer infectious as indicated by
AFB smear. AII requires a private room with special ventilation that dilutes and
removes airborne contaminants and controls the direction of airflow so that air pressure
inside the room is negative to the air pressure in the hallway. To enable adequate
function of this negative airflow system, the door to the room should be closed as much
as possible and the negative pressure monitored consistent with hospital policy. Persons
entering the AII room should wear N-95 respirators designed to provide a tight face seal
and filter particles in the 1- to 5-m range. Patients should wear a standard surgical
mask if it is necessary for them to leave the room.
Desired outcome
Following instruction, patient and significant others verbalize how TB is spread and
measures necessary to prevent the spread.
Nursing Interventions
Teach patient about TB and the mechanism by which it is spread (respiratory droplet
nuclei).
89
Remind staff and visitors of need to keep door closed to enable effective function of the
ventilation system.
Explain to staff and visitors the importance of wearing N-95 or other high-efficiency
respirators, including proper fit and use. Provide appropriate respirators at doorway or
other convenient place.
Teach patient importance of covering mouth and nose with tissue when sneezing or
coughing and of disposing used tissue in appropriate waste container.
Phone numbers to call if questions or concerns arise about therapy or disease after
discharge.
90
o Division of Tuberculosis Elimination at the Centers for Disease Control
and Prevention,www.cdc.gov/tb
BOX 2-1
DISEASE PROCESSES LEADING TO DEVELOPMENT OF RESPIRATORY FAILURE
Impaired Alveolar Ventilation
91
Pulmonary emboli
Atelectasis
Pneumonia
Emphysema
Chronic bronchitis
Bronchiolitis
Diffusion Disturbances
Pulmonary/interstitial fibrosis
Pulmonary edema
92
ARDS
* Progression of respiratory failure in certain diagnoses can lead to acute lung injury and acute
respiratory distress syndrome. Acute lung injury is characterized by bilateral pulmonary
infiltrates on chest x-ray; noncardiogenic pulmonary edema; and a Pa o 2 /FI o 2 (P/F) ratio of
less than 300. P/F ratio is the relationship of arterial blood gas (Pa o 2 ) to inspired
O 2 concentration (FIo 2 ). Normal P/F ratio is approximately 500 (100/0.20). In a patient with
Pa o2 of 80 mm Hg and FI o 2 of 0.40, the P/F ratio would be 200 (80/0.40).
ARDS is characterized by all of the above criteria with a P/F ratio of less than 200. Acute
lung injury is most often seen as part of a systemic inflammatory response, usually
sepsis or other direct lung injury. The inflammatory response causes widespread
destruction of alveolar capillary endothelia, extravasculation of protein-rich fluid, and
interstitial edema in the alveoli. As a result, alveolar membranes become damaged by
fluid filling the alveoli, with resulting destruction of surfactant production. This leads to
refractory hypoxemia (increased O 2 requirements that necessitate a large amount of
inspired oxygen), noncompliant lungs, and a profound ventilation/perfusion mismatch.
Alveolar hypoventilation
Occurs secondary to reduction in alveolar minute ventilation. Because differential
indicators (cyanosis, somnolence) occur late in the process, the condition may go
unnoticed until tissue hypoxia is severe.
Ventilation/perfusion mismatch
Considered the most common cause of hypoxemia. Normal alveolar ventilation occurs at
a rate of 4 L/min, with normal pulmonary vascular blood flow occurring at a rate of
93
5 L/min. Normal ventilation/perfusion ratio is 0.8:1. Any disease process that
interferes with either side of the equation upsets physiologic balance and can lead to
respiratory failure as a result of reduction in arterial O 2 levels.
Diffusion disturbances
Processes that physically impair gas exchange across the alveolar-capillary membrane.
Diffusion is impaired because of the increase in anatomic distance the gas must travel
from alveoli to capillary and capillary to alveoli.
Right-to-left shunt
Occurs when the previously mentioned processes go untreated. Large amounts of blood
pass from the right side of the heart to the left and out into the general circulation
without adequate ventilation; therefore blood is poorly oxygenated. This mechanism
occurs when alveoli are atelectatic or fluid filled, inasmuch as these conditions interfere
with gas exchange. Unlike the first three responses, hypoxemia secondary to right-to-left
shunting does not improve with O 2 administration because despite the increare in
inspired oxygen concentration (FI o 2 ) the additional oxygen is unable to cross the
alveolar-capillary membrane.
Assessment
Clinical indicators of ARF vary according to the underlying disease process and severity
of the failure. ARF is one of the most common causes of impaired level of consciousness
(LOC). Often it is misdiagnosed as heart failure, pneumonia, or stroke.
Intermediate
Confusion, increased agitation, and increased O 2 requirements with decreased
O 2 saturations. Patients who have hypoventilation respiratory failure often exhibit
lethargy and bradypnea. Patients with ventilation/perfusion mismatch often exhibit
tachypnea.
Late
Cyanosis, diaphoresis, coma, respiratory arrest.
Diagnostic Tests
Arterial blood gas (ABG) analysis
Assesses adequacy of oxygenation and effectiveness of ventilation and is the most
important diagnostic tool. Typical results are Pa o 2 60 mm Hg or less, Pa co 2 45 mm Hg
or more, and pH less than 7.35, findings consistent with severe respiratory acidosis.
94
Chest x-ray examination
Ascertains presence of underlying pathophysiology or disease process that may be
contributing to the failure.
Collaborative Management
Treatment is aimed at correcting the acid-base disturbance while treating underlying
pathophysiology in an effort to prevent or correct ARF. Although the general rule is to
bring the Pa o 2 to greater than 60 mm Hg and the Paco 2 to 35-45 mm Hg, patients with
chronic obstructive pulmonary disease (COPD) may be clinically stable with
Pa co 2 greater than 45 mm Hg; therefore determination of pH is critical in these
individuals. For example, patients with chronically high Pa co 2 whose pH drops to less
than baseline are at risk for ARF.
O therapy
2
Bronchodilator therapy
Delivered via nebulizer or noninvasive positive-pressure ventilation (NIPPV). It may
eliminate necessity for intubation and mechanical ventilation.
Coughing/deep-breathing exercises
Mobilize secretions and promote full lung expansion. If cough is ineffective, suctioning
may be necessary to stimulate cough reflex and clear secretions. Intermittent positive-
pressure breathing (IPPB) may be used for patients who are unable to use incentive
spirometer to assist with lung expansion.
95
Sclerosis, p. 229 ; and Guillain-Barr Syndrome, p. 238 , because these disorders may
be precursors to ARF.
In the central airways, inflammatory cells infiltrate the surface epithelium. Enlarged
mucus-secreting glands and an increased number of goblet cells lead to mucus
hypersecretion. In smaller airways, chronic inflammation leads to repeated cycles of
injury to the airway wall. Repair of the airway wall results in increased collagen content
and scar tissue formation that narrow the lumen and produce fixed airway obstruction.
Assessment
Signs and symptoms/physical findings
Chronic cough (usually the first symptom) followed by dyspnea (usually reason for
seeking health care) with a prolonged expiratory phase. As lung function deteriorates,
perceived increase in work of breathing (WOB), wheezing, chest tightness, use of
accessory muscles of respiration, digital clubbing, decreased thoracic expansion, barrel
chest appearance, dullness over areas of consolidation, adventitious breath sounds
(especially coarse rhonchi and wheezing). Signs of COPD-related right-sided heart
failure: include ankle edema, distended neck veins, hepatic congestion, and bloated
appearance. See BOX 2-2 .
BOX 2-2
INDICATORS FOR DIAGNOSING COPD
Chronic Cough
96
Chronic Sputum
Dyspnea
Tobacco smoke
97
Diagnostic Tests
Chest x-ray
Rules out other causes of airway obstruction and lung cancer.
Oximetry
Reveals decreased O 2 saturation (90% or less).
Spirometry
Confirms diagnosis of COPD. Clinical indicators and the forced expiratory volume in
1 sec (FEV 1 ) diagnose and classify severity of COPD. See TABLE 2-3 . Should be
monitored annually and during acute illness.
TABLE 2-3
CLASSIFICATION OF COPD SEVERITY
STAGE CHARACTERISTICS
0: At risk Normal spirometry
Chronic symptoms (cough, sputum production)
I: Mild FEV 1 /FVC less than 70%
98
STAGE CHARACTERISTICS
FEV 1 80% or more predicted
With or without chronic symptoms (cough, sputum production)
II: Moderate FEV 1 /FVC less than 70%
50% FEV 1 less than 80% predicted
With or without chronic symptoms (cough, sputum production)
III: Severe FEV 1 /FVC less than 70%
30% FEV 1 less than 50% predicted
With or without chronic symptoms (cough, sputum production)
IV: Very FEV 1 /FVC less than 70%
severe
FEV 1 less than 30% predicted or FEV 1 less than 50% predicted plus
chronic respiratory failure
View full size
FEV 1 , Forced expiratory volume in 1 second; FVC, forced vital capacity.
Sputum culture
May reveal presence of infective organisms. Sputum specimens are best collected when
the patient first wakes in the morning.
Differential diagnosis
COPD may mimic many other diseases such as asthma, heart failure, bronchiectasis,
tuberculosis (TB), obliterative bronchiolitis, and diffuse bronchiolitis.
Collaborative Management
O therapy
2
Smoking cessation
Single most effective way of reducing risk of development and progression of COPD.
Nicotine replacement therapy also should be considered to assist with withdrawal from
tobacco.
99
Pulmonary rehabilitation
A comprehensive program includes exercise training, nutrition counseling, and
education. Patients who have completed a pulmonary rehabilitation program have been
shown to have improved quality of life and slowed progression of the disease.
Pharmacotherapy
Inhaled bronchodilators
Open airways by relaxing smooth muscles of the airways. The resultant increased
airflow may help loosen mucus.
Inhaled steroids
Result in a small, one-time increase in FEV 1 , decrease frequency and severity of
exacerbations, and reduce mortality.
Antibiotics
Prescribed based on presence of infiltrate on chest x-ray film and other signs of
infection.
IV or oral fluids
Administered to promote adequate hydration.
Diuretics or Na restriction
+
Desired outcomes
Following intervention, patient coughs appropriately and has effective airway clearance
as evidenced by absence of adventitious breath sounds.
Nursing Interventions
100
Auscultate breath sounds q2-4h (or as indicated by patient's condition) and after
coughing. Be alert to and report changes in adventitious breath sounds.
Teach patient the double cough technique to prevent small airway collapse, which can
occur with forceful coughing.
When not otherwise indicated, encourage fluid intake (2.5 L/day or more) to decrease
sputum viscosity.
Desired outcome
For a minimum of 24 hr before hospital discharge, patient has adequate nutrition as
evidenced by stable weight, positive N balance, and serum albumin 3.5-5.5 g/dL.
Nursing Interventions
Monitor food and fluid intake. If indicated, obtain dietary consultation for calorie
counts.
Provide diet in small, frequent meals that are nutritious and easy to consume.
101
Request consultation with dietitian so that patient can verbalize food likes and dislikes.
Unless otherwise indicated, provide calories more from unsaturated fat sources ( BOX 2-
3 ) than from carbohydrate sources. During the process of carbohydrate metabolism,
the body uses O 2 and produces CO2 , which is then excreted by the lungs. Patients with
COPD take in less O 2 and retain CO 2 . A high-fat diet minimizes this problem because
fat generates the least amount of CO 2 for a given amount of O 2 used, whereas
carbohydrates generate the most.
BOX 2-3
RECOMMENDED CALORIE SOURCES FOR PATIENTS WITH COPD
Foods High in Fat
o
Cheese
Cream
Cream soups
Custards
Evaporated milk
Fish
Margarine
Mayonnaise
102
Meat
Nuts
Poultry
Whole milk
Foods to Avoid
o
Cakes
Cookies
Jams
Pastries
Sugar-concentrated snacks
Discuss with patient and significant others the importance of good nutrition in the
treatment of COPD.
Desired outcome
103
Following treatment/intervention, patient's breathing pattern improves as evidenced by
reduction in or absence of dyspnea and movement toward a state of eupnea.
Nursing Interventions
Assess respiratory status q2-4h and be alert for indicators of respiratory distress (i.e.,
agitation, restlessness, changes in mental status, decreased level of consciousness
(LOC), use of accessory muscles of respiration). Auscultate breath sounds; report a
decrease in breath sounds or an increase in adventitious breath sounds.
Teach pursed-lip breathing, which increases intraluminal air pressure and thus
promotes internal stability of the airways and may prevent airway collapse during
expiration. Record patient's response to breathing technique.
Sit upright with hands on thighs, or lean forward with elbows propped on over-the-bed
table.
Exhale slowly through pursed lips. Exhalation should take twice as long as inhalation
(e.g., count to 5 on inhalation; count to 10 on exhalation).
104
Monitor oximetry readings; report O 2 saturation 92% or less because this can indicate
need for O 2therapy.
Monitor serial ABG values. Patients with chronic CO 2 retention may have chronically
compensated respiratory acidosis with low normal pH (7.35-7.38) and Pa co 2 greater
than 45 mm Hg.
Activity intolerance
related to imbalance between O 2 supply and demand secondary to inefficient work of
breathing
Desired outcome
Patient reports decreasing dyspnea during activity or exercise and rates perceived
exertion at 3 or less on a 0-10 scale.
Nursing Interventions
Facilitate coordination among health care providers to ensure rest periods between care
activities to decrease O 2 demand. Allow 90 min for undisturbed rest.
Assist patient with active ROM exercises to build stamina and prevent complications of
decreased mobility . For more information, see Risk for activity intolerance in
Prolonged Bed Rest, p. 23 .
105
Use of home O 2 , including when to use it, importance of not increasing prescribed flow
rate, precautions, and community resources for O 2 replacement when necessary.
Request respiratory therapy consultation to assist with teaching related to O 2 therapy, if
indicated.
Medications, including drug names, route, purpose, dosage, schedule, precautions, and
potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions. If
patient will be taking oral corticosteroids while at home, provide instructions
accordingly to ensure patient takes the correct amount, particularly during the period in
which medication will be tapered.
Signs and symptoms of heart failure that necessitate medical attention: increased
dyspnea, fatigue, and coughing; changes in amount, color, or consistency of sputum;
swelling of ankles and legs; fever; and sudden weight gain. For more information, see
Heart Failure, p. 107 .
Review of Na + -restricted diet (see Box 4-1 , p. 165 ) and other dietary considerations as
indicated.
Follow-up appointment with health care provider; confirm date and time of next
appointment.
106
Introduction to pulmonary rehabilitation programs.
Section FourAsthma
Overview/Pathophysiology
Asthma is a chronic disorder characterized by an exaggerated bronchoconstrictive
response to selective stimuli, recurrent and reversible obstruction of airflow in the
bronchioles and smaller bronchi, and inflammation. Infiltration of the airways by
inflammatory cells such as activated lymphocytes and eosinophils, denudation of the
epithelium, deposition of collagen in the membrane, and presence of mast cells are often
found in mild and moderate asthma. Severe asthma can lead to occlusion of the
bronchial lumen by mucus, hyperplasia, and hypertrophy of the bronchial smooth
muscles and hyperplasia of goblet cells. Over time, this inflammation can lead to
remodeling and damage to the airways.
Assessment
Signs and symptoms/physical findings
Tachypnea, dyspnea, orthopnea, wheezing, coughing (often worse at night and in the
morning), chest tightness, increased sputum production, tachycardia, anxiety, agitation,
prolonged expiratory phase, use of accessory muscles of respiration, chest retractions
(supraclavicular area, intercostal and suprasternal spaces), hyperexpansion of the
thorax, hyperresonance, pulsus paradoxus, diaphoresis, and pallor.
Symptoms occur or worsen in the presence of exercise, viral infections, animals with fur
or feathers, house-dust mites, mold, smoke (tobacco, wood), pollen, changes in weather,
strong emotional expression (crying), airborne chemicals or dusts, and menses. If
symptoms are left untreated, an acute asthmatic attack can progress to status
asthmaticus (SA), a severe and unrelenting asthma attack. SA is an exhausting condition
that results in respiratory insufficiency and hypoxia, and it may result in death if
untreated.
Diagnostic Tests
Oximetry
Reveals decreased O 2 saturation (90% or less).
107
Chest x-ray examination
Usually normal; lung hyperinflation may be seen with severe asthma.
CBC
May show increased WBCs with concurrent infection. Differential may show increased
eosinophils, which indicates an allergic response.
Sputum
Gross examination may reveal increased viscosity or actual mucus plugs. Culture and
sensitivity may reveal microorganisms if infection was the precipitating event.
Spirometry
Evaluates degree of airflow obstruction. Partially reversible obstruction (a more than
12% increase and 200 mL in FEV 1 after inhaling a short-acting bronchodilator or after
receiving a short course of oral corticosteroids) is diagnostic.
ECG results
Sinus tachycardia is an important baseline indicator because use of some
bronchodilators may produce cardiac stimulant effects and dysrhythmias. Prominent P
waves appear in chronic asthma.
Collaborative Management
Primarily, management is directed toward monitoring for and preventing acute asthma
attacks.
Generally, these patients experience mild to moderate hypoxemia. Low-flow (1-3 L/min)
O 2 is delivered via nasal cannula with humidity for O 2 saturation of less than 90%.
Pharmacotherapy
Initiated to relieve bronchospasm and continued until wheezing subsides and PFTs
return to baseline.
108
Bronchodilators
Dilate smooth muscles of the airways. Nebulizer/aerosolized bronchodilators are used
for acute exacerbation of symptoms.
Corticosteroids
Inhibit the inflammatory response. Acute adrenal insufficiency can develop in patients
who take steroids routinely at home if these drugs are not given to the patient during
hospitalization.
IV Steroids (Methylprednisolone)
Used to gain control of inflammation in severe attacks. Dosage varies according to
severity of the episode and whether patient is currently taking steroids.
Oral Steroids
Once stabilized, the patient in acute phase begins taking oral steroids. Steroids are used
cautiously in patients with tuberculosis (TB), diabetes, and peptic ulcer.
Antibiotics
Initiated if there is concurrent fever, leukocytosis, purulent sputum, or unsuspected
bacterial sinusitis.
Fluid replacement
Needed to maintain adequate hydration.
Long-Term Control
Nebulizer/aerosolized bronchodilators
Usually prescribed for short-term use for acute exacerbations of symptoms. However,
some patients require maintenance doses to prevent recurrent attacks.
Steroids
Systemic corticosteroids (prednisone or methylprednisolone)
Usually, patients are gradually weaned from steroids over 2-3 wk. Some patients may
require low-dose steroids indefinitely.
Inhaled steroids
Mainstay of interim therapy to prevent or reduce the incidence of acute asthmatic
attacks. Dosage is commonly 2-4 inhalations 2-4 /day. Some patients use inhalant
bronchodilators simultaneously with steroid inhalers. To maximize effectiveness of the
steroid inhaler, these patients should be taught to use the bronchodilator as prescribed,
wait 10-15 min, and then use the steroid inhaler. Use of steroid inhalers may result in
fungal overgrowth of the mouth or pharynx; patient should rinse mouth after each dose.
109
Nonsteroidal antiinflammatory inhalers (cromolyn, nedocromil sodium)
These agents are believed to mediate endothelial response to allergens and thus prevent
bronchospasm. Cromolyn is believed to inhibit secretion of the slow-reacting substance
of anaphylaxis (SRS-A) from mast cells. Not all patients benefit from cromolyn. Usual
dosage is 2-4 inhalations 2-4/day.
Desired outcomes
Following treatment/intervention, patient has adequate gas exchange as evidenced by a
respiratory rate (RR) of 12-20 breaths/min (or values consistent with patient's
baseline). Before hospital discharge, patient's ABG values are as follows:
Pa o 2 80 mm Hg or higher, Pa co 2 35-40 mm Hg, and pH 7.35-7.45, or oximetry
readings demonstrating O 2 saturation greater than 90%. Patient reports decreased
dyspnea and diminished to no wheezes.
Nursing Interventions
Observe for signs and symptoms of hypoxia (e.g., agitation, mental status changes,
anxiety, restlessness, changes in mental status or level of consciousness (LOC)).
Remember that cyanosis of the lips and nail beds is a late indicator of hypoxia.
110
Auscultate breath sounds q2-4h or more frequently as indicated by patient's condition.
Monitor for decreased or adventitious sounds (e.g., crackles [rales], rhonchi, wheezes).
Monitor oximetry readings; report O 2 saturation 90% or less because this can indicate a
need for O 2therapy.
Signs and symptoms of acute exacerbation (e.g., increased cough; increased dyspnea,
especially at night or during activity; wheezing).
Medications, including drug names, route, purpose, dosage, precautions, and potential
side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.
Proper use of metered-dose inhalers, including use of a spacer (if indicated) to facilitate
medication inhalation. Document adequate return demonstration by the time of
hospital discharge. Remind patient that over-the-counter (OTC) inhalers contain
medications that can interfere with prescribed therapy. Instruct patient to contact
health care provider before taking any OTC medications.
111
If patient will take corticosteroids while at home, provide instructions accordingly to
ensure that patient takes the correct amount, particularly during the period in which the
medication will be tapered.
Development of an asthma action plan, which includes peak flow readings, symptoms,
and use of rescue medications. An asthma action plan is a risk-stratified outline for
steps to take if patient experiences an asthma attack. Many action plans also list
emergency medications and contact information.
Smoking cessation: the single most effective way to reduce asthma attacks. With every
interaction, patients should be asked about their smoking status and advised of the
importance of quitting, even if they have quit within the past year. A counseling session
should include social support and scheduled follow-up visits. Nicotine replacement
therapy also should be considered to assist with withdrawal from tobacco.
Phone numbers to call if questions or concerns arise about therapy or disease after
discharge. Additional general information can be obtained from the following resource:
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112
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113
The Client with Alterations in Hematologic and
Immune Function
Nancy Haugen PhD, RN
Ulrich & Canale's Nursing Care Planning Guides (NANDA), CHAPTER 7, 449-484
HIV has been isolated from all body fluids, but at this point, transmission has been
associated only with blood, semen, amniotic fluid, vaginal secretions, and breast milk.
The known routes of transmission are by intimate sexual contact, mucous membrane or
percutaneous exposure to infected blood or blood products, and perinatal transmission
from mother to child. The four high-risk groups for acquiring HIV infection are
heterosexuals with multiple sexual partners, men who have sex with men, intravenous
drug users, and recipients of blood/blood products. Treating HIV-infected women
during pregnancy with an antiretroviral agent (e.g., zidovudine) has significantly
reduced the transmission of HIV from mother to child.
Infection with HIV tends to follow a particular course, with the clinical expression being
attributed to either the effects of the virus itself or the consequences of CD4 + T-
lymphocyte depletion. The initial event in the course of the disease is acute retroviral
infection, which occurs about 1 to 6 weeks after exposure to HIV. The person
experiences symptoms such as fever, headache, myalgias, lymphadenopathy, rash,
fatigue, and sore throat that may persist for a week or longer. Then, the HIV-infected
person enters the chronic infection stage. In the early period of chronic infection, the
person may be asymptomatic or continue to experience mild symptoms such as fatigue,
headache, and lymphadenopathy. This early period often lasts as long as 10 to 12 years,
114
depending on the rate of viral replication and the rapidity of CD4 + T-lymphocyte
destruction. The symptomatic stage of HIV infection develops when the CD4 + T-
lymphocyte count drops below 500 cells/mm 3 and the HIV viral load rises above
10,000 copies/mL. In the early symptomatic stage, the person has various nonspecific
symptoms (e.g., unexplained fever and weight loss, fatigue, night sweats, peripheral
neuropathy, persistent diarrhea) and persistent, localized viral or fungal infections.
AIDS is the last stage of HIV infection. In addition to the symptoms experienced in the
previous stage, AIDS is heralded by immune suppression (serologically defined as a
CD4 + T-lymphocyte count < 200 cells/mm 3 ) and the presence of a condition that
meets the criteria for definition of an AIDS case as specified by the Centers for Disease
Control and Prevention (CDC). These AIDS-indicator conditions include HIV-related
encephalopathy, HIV wasting syndrome, opportunistic infections (e.g.,Pneumocystis
jiroveci pneumonia [formerly known as pneumocystis carinii PCP]; candidiasis of
esophagus or bronchi, trachea, or lungs; Mycobacterium
tuberculosis , Mycobacterium avium complex [MAC]; extrapulmonary
cryptococcosis; cytomegalovirus infection; Toxoplasma encephalitis;
coccidioidomycosis), and AIDS-related cancers (e.g., Kaposi's sarcoma, non-Hodgkin's
lymphoma, invasive cervical cancer).
At this time, there is no cure for HIV infection. However, there have been significant
advances in antiretroviral therapy and prevention of opportunistic infections that have
increased the long-term survival of persons with HIV infection. Earlier treatment and
the use of highly active antiretroviral therapy (HAART), which consists of a combination
of at least three antiretroviral agents, have made significant differences in sustaining
viral suppression, slowing disease progression, and reducing drug resistance. Because of
the side effects of the antiretroviral agents and lack of adherence to the drug regimen,
current federal guidelines suggest that treatment be offered early, but that it can be
delayed until higher levels of immune suppression are observed.
The antiretroviral agents used to control viral replication of HIV include nucleoside
reverse transcriptase inhibitors (e.g., zidovudine, lamivudine, zalcitabine, abacavir,
didanosine, stavudine), protease inhibitors (e.g., saquinavir, ritonavir, indinavir,
amprenavir, nelfinavir), nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine,
delavirdine, efavirenz), and fusion inhibitors (e.g., enfuvirtide). Chemoprophylactic
therapy to prevent AIDS-defining opportunistic infections has also led to a significant
decline in the incidence of certain diseases such as PCP, MAC, tuberculosis, and
toxoplasmosis.
This care plan focuses on the adult client with HIV infection hospitalized
for treatment of a probable opportunistic infection. Much of the
information is applicable to clients receiving follow-up care in an
extended care facility or home setting.
OUTCOME/DISCHARGE CRITERIA
The client will:
1.
115
Have an adequate respiratory status
2.
3.
4.
5.
6.
7.
Show evidence that skin and oral mucous membranes are intact or healing appropriately
8.
9.
10.
11.
12.
13.
116
Share feelings about changes in mental and physical functioning and the social isolation
and loneliness that may result from having AIDS
14.
Identify resources that can assist with financial needs and adjustment to changes
resulting from the diagnosis of AIDS
15.
Definition: Inspiration and/or expiration that does not provide adequate ventilation;
inability to clear secretions or obstructions from the respiratory tract to maintain a clear
airway
Decreased depth of respirations associated with fear, anxiety, weakness, fatigue, and
chest pain if present
Increased rate of respirations associated with fear, anxiety, and the increase in
metabolic rate that occurs with infection
Stasis of secretions associated with decreased activity and poor cough effort resulting
from fatigue and pain
117
Impaired gas exchange NDx related to a decrease in effective lung surface associated
with:
The presence of infiltrates and/or cavities in the lung tissue resulting from opportunistic
infection of the lungs (e.g., PCP, pneumococcal pneumonia, tuberculosis,
histoplasmosis)
CLINICAL MANIFESTATIONS
Subjective Objective
Reports of difficulty vocalizing; Dyspnea; orthopnea; diminished breath sounds;
verbal reports of restlessness adventitious breath sounds; cough; change in
respiratory rate and rhythm
View full size
RISK FACTORS
Pulmonary infection
Immunosuppression
Mycobacterium tuberculosis
DESIRED OUTCOMES
The client will experience adequate respiratory function as evidenced by:
a.
b.
118
Decreased dyspnea
c.
d.
e.
f.
g.
NOC OUTCOMES
Respiratory status: airway patency; respiratory status: ventilation; respiratory status:
gas exchange
NIC INTERVENTIONS
Respiratory monitoring; airway management; chest physiotherapy; cough
enhancement; ventilation assistance; oxygen therapy; medication administration
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms
symptoms of impaired respiratory function: of impaired respiratory function allows for
prompt intervention.
Dyspnea, orthopnea
119
RATIONALE
Use of accessory muscles when breathing
120
RATIONALE
hours.
121
RATIONALE
Perform actions to promote removal of
pulmonary secretions:
122
RATIONALE
more deeply and participate in activities to
improve respiratory status.
Perform actions to reduce pain and
fatigue:
Consult appropriate health care provider Consulting the appropriate health care
(e.g., respiratory therapist, physician) if provider allows for modification of the
signs and symptoms of impaired treatment plan.
123
RATIONALE
respiratory function persist or worsen.
View full size
Neuropathic pain related to the effect of HIV, some opportunistic infections, and
some medications (e.g., didanosine, zalcitabine, isoniazid) on the peripheral nerves
124
Muscle strain associated with excessive coughing if present
CLINICAL MANIFESTATIONS
Subjective Objective
Verbal report of pain Inability to breathe deeply, ambulate, sleep, or perform
identifying the level of activities of daily living; crying; muscle rigidity;
intensity using a pain rating diaphoresis; blood pressure (B/P) or pulse changes;
scale; loss of appetite increase in the rate and depth of breathing
View full size
RISK FACTORS
Injury agents
DESIRED OUTCOMES
The client will experience diminished pain as evidenced by:
a.
b.
c.
125
Increased participation in activities
d.
NOC OUTCOMES
Comfort level; pain control; pain: disruptive effects
NIC INTERVENTIONS
Pain management; environmental management: comfort; analgesic administration
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms Early recognition of signs and symptoms
of pain: of acute or chronic pain allows for prompt
intervention.
Verbalization of pain
Grimacing
Rubbing head
Reluctance to eat
Restlessness
Diaphoresis
126
RATIONALE
Increased B/P
Tachycardia
Location
Quality
Onset
Duration
Precipitating factors
Aggravating factors
Alleviating factors
127
RATIONALE
pain effectively.
View full size
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to reduce pain: D
Actions help promote relaxation and
subsequently increase the client's
Perform actions to reduce fear and anxiety threshold and tolerance for pain.
about the pain experience:
128
RATIONALE
threshold and tolerance for pain.
Position change
Guided imagery
Restful environment
129
RATIONALE
Dependent/Collaborative Actions
Implement measures to reduce pain:
130
RATIONALE
(e.g., capsaicin)
Consult appropriate health care provider if Consulting the appropriate health care
adequate pain relief cannot be achieved provider allows for modification of the
with the above measures. treatment plan.
View full size
Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN
BODY REQUIREMENTS NDx
Definition: Intake of nutrients insufficient to meet metabolic demands
Related to:
Anorexia resulting from malaise, fatigue, fear, anxiety, pain, depression, increased levels
of certain cytokines that depress appetite (e.g., tumor necrosis factor [TNF]), and some
antiretroviral agents
131
o
Oral pain and/or dysphagia resulting from opportunistic lesions in the mouth, pharynx,
and esophagus
CLINICAL MANIFESTATIONS
Subjective Objective
Self report of inadequate Body weight 20% or more under ideal body weight; loss
food intake; reported lack of of weight with adequate food intake; weakness of
food; aversion to eating; lack muscles required for swallowing or chewing; sore,
of interest in food inflamed buccal cavity; hyperactive bowel sounds;
diarrhea; excessive hair loss
View full size
RISK FACTORS
Biological factors
132
DESIRED OUTCOMES
The client will maintain an adequate nutritional status as evidenced by:
a.
b.
Normal blood urea nitrogen (BUN) and serum albumin, prealbumin, hematocrit (Hct),
and hemoglobin (Hgb) levels and lymphocyte count
c.
d.
NOC OUTCOMES
Appetite; nutritional status
NIC INTERVENTIONS
Nutritional monitoring; nutritional management; nutritional therapy; exercise
promotion: strength training; nausea management
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms of
symptoms of malnutrition: malnutrition allows for prompt intervention.
133
RATIONALE
Sore, inflamed oral mucous
membrane
Pale conjunctiva
Lower-than-normal
anthropomtrie measurements:
Skinfold thickness
134
RATIONALE
Independent Actions
Implement measures to maintain an adequate nutritional status:
Actions help to reduce
oral/pharyngeal pain and improve
Perform actions to improve oral intake: swallowing.
135
RATIONALE
Implement measures to reduce pain.
136
RATIONALE
oxygen therapy during meals.
Dependent/Collaborative Actions
Implement measures to maintain an adequate Decreases nausea
nutritional status:
137
RATIONALE
Elemental formulas
Appetite stimulants
Anabolic agents
138
RATIONALE
appetite and promote weight gain by
suppressing TNF- production (use of
Cytokine inhibitors (e.g., Thalidomide) thalidomide is reserved for persons
with severe HIV-related wasting).
Perform a calorie count if ordered. Report
information to dietitian and physician.
Consult physician or physical therapist about a Exercise is necessary to promote the
progressive exercise program. maintenance/buildup of lean body
mass and help prevent wasting.
Consult physician about an alternative method Consulting the appropriate health
of providing nutrition if client does not care provider allows for modification
consume enough food or fluids to meet of the treatment plan.
nutritional needs:
Parenteral nutrition
Tube feedings
Related to:
Excessive loss of fluid associated with diarrhea, diaphoresis, and vomiting if present
139
Decreased oral intake associated with anorexia, weakness, nausea, and oropharyngeal
pain
Excessive loss of sodium associated with diarrhea, profuse diaphoresis, and vomiting if
present
Excessive loss of sodium associated with diarrhea, profuse diaphoresis, and vomiting if
present
Water retention associated with increased antidiuretic hormone (ADH) output resulting
from opportunistic disease involvement of the lungs or central nervous system
CLINICAL MANIFESTATIONS
Subjective Objective
Verbal reports of Change in mental status; decreased skin turgor; postural
weakness; hypotension; weak, rapid pulse; decreased urine output; cardiac
confusion dysrhythmias; nausea and vomiting; absent bowel sounds
View full size
RISK FACTORS
Abdominal ascites
140
Sepsis
DESIRED OUTCOMES
The client will maintain fluid and electrolyte balance as evidenced by:
a.
b.
c.
Stable weight
d.
B/P and pulse within normal range for client and stable with position change
e.
f.
g.
h.
i.
j.
k.
BUN, Hct, and serum potassium and sodium levels within normal range
141
NOC OUTCOMES
Fluid balance; hydration; electrolyte and acid-base balance
NIC INTERVENTIONS
Fluid management; electrolyte management: hypokalemia; electrolyte management:
hyponatremia
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms of
symptoms of: imbalanced fluid and electrolytes allow for
prompt intervention.
142
RATIONALE
Decreased urine output (reflects an
actual rather than potential fluid
deficit)
Hypokalemia
Cardiac dysrhythmias
Postural hypotension
Muscle weakness
Abdominal distention
Hyponatremia
Abdominal cramps
143
RATIONALE
Lethargy
Confusion
Weakness
Seizures
144
RATIONALE
axillae).
Bananas
Avocado
Potatoes
Raisins
Cantaloupe
Processed cheese
Canned soups
Canned vegetables
145
RATIONALE
Bouillon
Dependent/Collaborative Actions
Implement measures to prevent or treat
imbalanced fluid and electrolytes:
Nausea often causes the client to
have decreased fluid intake. Preventing
Administer antiemetics if ordered to control vomiting results in excessive loss of
vomiting. fluid.
Consult physician if signs and symptoms of Consulting the appropriate health care
imbalanced fluid and electrolytes persist or provider allows for modification of the
worsen. treatment plan.
View full size
Nursing Diagnosis HYPERTHERMIA NDx
Definition: Body temperature elevated above normal range
CLINICAL MANIFESTATIONS
Subjective Objective
Verbal reports of Increase in body temperature above normal range; flushed skin;
headache warm to touch; increased respiratory rate; tachycardia; seizures;
convulsions
View full size
RISK FACTORS
146
Illness
Medications
Dehydration
DESIRED OUTCOMES
The client will experience resolution of hyperthermia as evidenced by:
a.
b.
c.
d.
NOC OUTCOMES
Thermoregulation
NIC INTERVENTIONS
Fever treatment
NURSING ASSESSMENT
RATIONALE
Assess for signs and Early recognition of signs and symptoms of hyperthermia
147
RATIONALE
symptoms of hyperthermia: allows for prompt intervention.
Tachycardia
Tachypnea
Elevated temperature
Monitor and record all Excessive fluid loss that may occur with hyperthermia
sources of fluid loss. can potentiate the loss of fluid and electrolytes.
Monitor laboratory studies: Hyperthermia may be a symptom of infection. Monitoring
laboratory studies helps to identify possible contributing
factors.
Arterial blood gas values
Urinalysis
148
RATIONALE
demands on the cardiorespiratory system. A prolonged
fever may weaken a client by exhausting energy stores.
Perform actions to resolve If the source of the fever is a potential respiratory
the infectious process: infection, appropriate interventions that mobilize
secretions must be implemented.
Implement measures to
promote rest.
Implement measures to
maintain an adequate
nutritional status.
Implement measures to
promote removal of
pulmonary secretions if a
respiratory infection is
present.
Dependent/Collaborative Actions
Implement measures to Fever may be accompanied by diaphoresis, which can
reduce fever: result in excessive loss of fluid.
149
RATIONALE
Administer antimicrobials
as ordered.
Administer antipyretics if
ordered.
Consult physician if Consulting the appropriate health care provider allows for
temperature remains modification of the treatment plan.
higher than 38.5C
View full size
Nursing Diagnosis FATIGUE NDx
Definition: An overwhelming sustained sense of exhaustion and decreased capacity for
physical and mental work at usual level
Related to:
Increased energy utilization associated with the elevated metabolic rate that is present
with infection
Malnutrition
150
Treatment with medications that can cause bone marrow depression or red blood cell
(RBC) hemolysis (e.g., zidovudine, antineoplastic agents, trimethoprim-
sulfamethoxazole [TMP-SMX])
Side effects of some medications client may be receiving (e.g., narcotic [opioid]
analgesics, antiemetics, antianxiety or antipsychotic agents)
CLINICAL MANIFESTATIONS
Subjective Objective
Verbalization of overwhelming lack of energy; Lethargic or listless; drowsy;
tired; increase in physical complaints; compromised concentration;
compromised libido; inability to restore energy disinterest in surroundings;
even after sleep decreased performance
View full size
RISK FACTORS
151
Stress
Depression
Anemia
Malnutrition
DESIRED OUTCOMES
The client will experience a reduction in fatigue as evidenced by:
a.
b.
c.
NOC OUTCOMES
Endurance; energy conservation; rest; psychomotor energy
NIC INTERVENTIONS
Energy management; exercise promotion: strength training; nutrition management;
sleep enhancement; mood management
NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms of Early recognition and reporting of signs and
fatigue: symptoms of fatigue allow for prompt
intervention.
152
RATIONALE
inability to maintain usual routines
Lethargy
Time of day
153
RATIONALE
maximize the client's participation
154
RATIONALE
showering
155
RATIONALE
156
RATIONALE
workload and myocardial oxygen utilization,
thereby decreasing oxygen availability.
Discourage smoking and
excessive intake of beverages high
in caffeine such as coffee, tea, and
colas.
Dependent/Collaborative Actions
Implement measures to increase
strength and reduce fatigue:
Erythropoiesis-stimulating growth
factor to stimulate RBC production
(e.g., epoetin alfa)
157
RATIONALE
Administer stimulants if ordered(e.g.,
dextroamphetamine).
Consult appropriate health care Consulting the appropriate health care provider
provider (e.g., rehabilitation allows for modification of the treatment plan.
therapist, psychiatric nurse clinician,
physician) if signs and symptoms of
fatigue worsen.
View full size
Nursing Diagnosis DISTURBED THOUGHT PROCESSES NDx
Definition: Disruption in cognitive operations and activities
AIDS dementia complex resulting from a direct effect of HIV on the central nervous
system
Opportunistic infections and/or neoplasms involving the central nervous system (e.g.,
toxoplasmic encephalitis, cryptococcal meningitis, progressive multifocal
leukoencephalopathy, cytomegalovirus [CMV] encephalitis, primary central nervous
system lymphoma)
CLINICAL MANIFESTATIONS
Subjective Objective
Verbalization of hallucinations; Inaccurate interpretation of the environment;
delusions; memory distractibility; inappropriate social behavior;
deficit/problems decreased ability to make decisions
View full size
RISK FACTOR
Cerebral abscess
158
DESIRED OUTCOMES
The client will experience improvement in thought processes as evidenced by:
a.
b.
NOC OUTCOMES
Cognitive orientation; cognition; information processing
NIC INTERVENTIONS
Dementia management; behavior modification; medication administration
NURSING ASSESSMENT
RATIONALE
Assess client for disturbed thought Early recognition and reporting of signs and
processes: symptoms of disturbed thought processes
allow for prompt intervention.
Impaired memory
Poor reasoning
Apathy
159
RATIONALE
Agitation
Hallucinations
Confusion
160
RATIONALE
simple language and short sentences.
161
RATIONALE
Encourage significant others to be supportive of
client; instruct them in methods of dealing with
client's disturbed thought processes.
Dependent/Collaborative Actions
162
RATIONALE
Brain biopsy
Neuropsychological tests
Consult appropriate health care provider (e.g., Consulting the appropriate health
psychiatric nurse clinician, physician) if disturbed care provider allows for
thought processes persist or worsen. modification of the treatment
plan.
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Nursing Diagnosis RISK FOR
INFECTION NDx (OPPORTUNISTIC INFECTION OR SEPSIS)
Definition: At increased risk for being invaded by pathogenic organisms
163
Related to:
CLINICAL MANIFESTATIONS *
* Specific objective and subjective symptoms will depend on site of infection and causative organism.
Subjective Objective
Verbal reports of pain at areas of Fever, chills, tachycardia, warm discharge over
impaired skin integrity areas of impaired skin integrity
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DESIRED OUTCOMES
164
The client will remain free of additional opportunistic infection and sepsis as evidenced
by:
1.
2.
3.
B/P within normal limits and pulse rate returning toward normal range
4.
5.
6.
7.
8.
9.
10.
11.
12.
165
Absence or resolution of heat, pain, redness, swelling, and unusual drainage in any area
13.
14.
15.
White blood cell (WBC) and differential counts returning toward normal range
16.
NOC OUTCOMES
Immune status; infection severity
NIC INTERVENTIONS
Infection control; infection protection
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of additional Early recognition of
opportunistic infection and sepsis (be alert to subtle changes signs and symptoms
in client since the signs of infection may be minimal as a of infection allows for
result of immunosuppression; also be aware that some signs prompt intervention.
and symptoms vary depending on the site of infection, the
causative organism, and the age of the client):
166
RATIONALE
Cloudy urine
167
RATIONALE
Visual disturbances
168
RATIONALE
Protect client from others with infection.
Urinary catheterization
Injections
Urinary
Intravenous
169
RATIONALE
Change equipment, tubings, and solutions used
for treatments such as intravenous infusions,
respiratory care, irrigations, and enterai feedings
according to hospital policy.
170
RATIONALE
171
RATIONALE
Dependent/Collaborative Actions
Implement measures to prevent further infection:
Agents to stimulate
production/enhance activity of the
Immunomodulating agents (e.g., interleukin-2, WBCs
colony-stimulating factors such as filgrastim and
sargramostim)
172
RATIONALE
Vaccines (e.g., hepatitis A, hepatitis B,
pneumococcal pneumonia, influenza)
* The nurse should select the diagnostic label that is most appropriate for the client's
discharge teaching needs.
NDx
Definition: Absence or deficiency of cognitive information related to specific topic
(lack of specific information necessary for clients/significant others to make informed
choices regarding condition/treatment/lifestyle changes); pattern of regulating and
integrating into family processes a program for treatment of illness and the sequelae of
illness that is unsatisfactory for meeting specific health goals; inability to identify,
manage, and/or seek out help to manage health
CLINICAL MANIFESTATIONS
173
Subjective Objective
Verbalization of the desire to Failure to include treatment in daily routines; failure
manage illness; verbalization of to take action to reduce risk factors; makes choices
difficulty with prescribed in daily living ineffective for meeting health goals;
regimen inadequate follow through of instruction
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RISK FACTORS
Cognitive limitations
Lack of recall
NOC OUTCOMES
Knowledge: disease process; knowledge: treatment regimen; knowledge: health
behavior; knowledge: health resources; knowledge: infection control
NIC INTERVENTIONS
Health system guidance; teaching: disease process; teaching: prescribed diet; teaching:
prescribed medication; communicable disease management; financial resource
assistance
NURSING ASSESSMENT
RATIONALE
Assess the client's baseline Understanding the client's baseline
understanding of: knowledge allows for implementation of the
appropriate interventions.
Disease process
Therapeutic regimen
174
RATIONALE
Health prevention measures
175
RATIONALE
equipment, or sexual devices.
176
RATIONALE
Safe sexual activity eliminates the risk of
exposure to HIV in semen and vaginal
If sexually active with a partner: secretions. Abstinence is the most effective
method.
177
RATIONALE
178
RATIONALE
179
RATIONALE
brittle or discolored or is sticky.
180
RATIONALE
items and surfaces (e.g., knives, cutting board,
countertop) before and after cooking, especially
when working with raw meat, poultry, and fish.
181
RATIONALE
contaminants that may lead to
viral or bacterial infection.
Wash hands after handling pets and avoid contact
with reptiles (e.g., snakes, lizards, turtles), baby
chickens, and ducklings.
182
RATIONALE
ways to maintain optimal nutritional status.
Independent Actions
Provide instructions regarding ways to Proper nutrition is essential to maintain
maintain an optimal nutritional status: body mass and ensure the necessary
levels of vitamins and nutrients.
183
RATIONALE
Night sweats
Swollen glands
Difficulty swallowing
184
RATIONALE
185
RATIONALE
to hemorrhoids
Seizures
186
RATIONALE
Stress the importance of adhering to the Adherence to the prescribed
prescribed treatment regimen. regimen can reduce
hospitalization, improve
Reinforce the importance of keeping scheduled outcomes, and aid in
follow-up appointments for laboratory studies and with maintaining optimal health
health care providers. status.
187
RATIONALE
symptoms to report, and ways to prevent infection.
Dry skin associated with deficient fluid volume (can occur as a result of decreased oral
intake, excessive diaphoresis, and/or persistent diarrhea)
188
Vulvovaginal candidiasis
Infections such as candidiasis, herpes simplex, oral hairy leukoplakia, and bacterial
gingivitis/periodontitis
Excessive scratching associated with pruritus (can occur with certain skin disorders or
as a side effect of some medications such as TMP-SMX)
189
Persistent contact with irritants associated with diarrhea
Damage to the skin and/or subcutaneous tissue associated with prolonged pressure on
tissues, friction, or shearing if mobility is decreased
FEAR/ANXIETY NDx
Related to:
Threat of permanent worsening of health status and possible disability and death
Threat to self-concept associated with changes in physical and mental functioning (e.g.,
wasting syndrome, gait difficulty, poor coordination, dementia)
190
Financial concerns
Depression, fear, anxiety, and ongoing grieving associated with the diagnosis of AIDS
and poor prognosis
Need for permanent change in lifestyle associated with impaired immune system
functioning and potential for disease transmission to others
Guilt associated with past behavior (if it was a factor in contracting HIV) and/or
possibility of having transmitted HIV to others
Lack of personal resources to deal with disability and premature death associated with
youth (a significant number of clients are in their 20s or 30s and are not
191
developmentally prepared to acknowledge and cope with disability and their own
mortality)
Multiple losses (e.g., death of close friends with AIDS; loss of normal body functioning,
family support, financial security, and/or usual lifestyle and roles)
Stigma and discrimination associated with the diagnosis of AIDS and others' fear of
contracting HIV
Decreased participation in usual activities because of weakness, pain, fatigue, and fear of
falls
Withdrawal from others associated with fear of embarrassment resulting from decline in
physical and mental functioning
192
Change in family roles and structure associated with progressive disability and eventual
death of family member
Financial burden associated with extended illness and progressive disability of client
Decisions made by client and his/her partner about such issues as treatment plan, life
support, and disposition of property that may be in conflict with the client's family of
origin
Anticipatory grief
Cognitive and/or motor impairments if present (can result from HIV or opportunistic
disease involvement of the CNS)
Depression
193
infection is present), unfamiliar environment, and the effect of some medications (e.g.,
zidovudine)
Decreased sexual desire associated with fatigue, pain, weakness, anxiety, depression,
and fear of transmitting or contracting disease
GRIEVING NDx
Related to:
Changes in body functioning, appearance, lifestyle, and roles associated with the disease
process
194
SEPSIS
Sepsis is a systemic response to infection. It is defined by the American College of Chest
Physicians and Society of Critical Care Medicine as a documented infection with a
finding of at least two of the four systemic inflammatory response criteria (i.e.,
temperature > 38C or below 36C; heart rate > 90 beats/min; respiratory rate > 20
breaths/min or partial pressure of carbon dioxide in arterial blood [Paco 2 ] < 32 mm
Hg; white blood cell [WBC] count > 12,000/mm 3 , < 4000/mm 3 , or > 10% immature
neutrophils).
Sepsis has become a leading cause of death in the United States. The increase in the
number of cases of sepsis is attributed to a number of factors including the increased
number of elderly persons and persons who are immunocompromised as a result of HIV
infection, more aggressive treatment with chemotherapy and radiation for cancer, and
treatment with corticosteroids and immunosuppressive agents. The increased use of
invasive diagnostic and therapeutic procedures has also led to increased exposure to
pathogens. In addition, the emergence of resistant organisms is making infections more
difficult to treat.
Once the causative organism enters the blood (referred to as septicemia or bacteremia),
the toxins produced by the pathogens initiate a widespread inflammatory and immune
response commonly referred to as the systemic inflammatory response syndrome
(SIRS). This inflammatory response is designed to be a protective process but if
uncontrolled, triggers the release of many inflammatory mediators that subsequently
cause widespread vasodilation, injury to the endothelium, and increased capillary
permeability. This chain of events can lead to maldistribution of circulating blood with
hypotension, hypoperfusion, and organ dysfunction. Septic shock, disseminated
intravascular coagulation (DIC), and multiple organ dysfunction syndrome (MODS) can
develop if this chain of events is not reversed.
This care plan focuses on care of the adult client hospitalized for
treatment of sepsis.
OUTCOME/DISCHARGE CRITERIA
The client will:
1.
195
2.
3.
4.
5.
6.
7.
Related to: Decreased pulmonary blood flow associated with a reduction in systemic
tissue perfusion resulting from inflammatory-mediated vasodilation, the fluid shift that
occurs with increased capillary permeability, and selective vasoconstriction
196
Accumulation of secretions in the lungs resulting from decreased mobility, poor cough
effort, and an increased production of secretions if a respiratory tract infection is
present
Accumulation of fluid in the lungs resulting from the generalized endothelial damage
and increase in capillary permeability that occur with a systemic inflammatory response
to severe infection
CLINICAL MANIFESTATIONS
Subjective Objective
Verbal reports of shortness of Confusion; restlessness; dyspnea; irritability;
breath; visual disturbances; somnolence; abnormal arterial blood gas values;
headache upon awakening abnormal skin color; abnormal rate and depth of
breathing; tachycardia; diaphoresis; polycythemia
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RISK FACTORS
DESIRED OUTCOMES
The client will experience adequate oxygen/carbon dioxide exchange as evidenced by:
a.
b.
c.
d.
197
NOC OUTCOMES
Respiratory status: gas exchange
NIC INTERVENTIONS
Respiratory monitoring; cough enhancement; chest physiotherapy; oxygen therapy
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of Early recognition of signs and
impaired gas exchange: symptoms of impaired gas exchange
allows for prompt intervention.
Restlessness, irritability
Confusion, somnolence
Tachypnea, dyspnea
198
RATIONALE
Improves lung expansion
199
RATIONALE
[PEP] device) if ordered.
Consult appropriate health care Allows for modification of the treatment plan
provider (respiratory therapist,
physician) if signs and symptoms of
impaired gas exchange persist or
worsen.
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Nursing Diagnosis INEFFECTIVE TISSUE PERFUSION NDx
Definition: Decrease in oxygen resulting in failure to nourish the tissues at the
capillary level. NANDA International identifies five types of ineffective tissue perfusion:
renal, gastrointestinal, peripheral, cerebral, and cardiopulmonary
Related to:
Maldistribution of circulating blood associated with vasodilation, fluid shift that occurs
with increased capillary permeability, and selective vasoconstriction that occur in
response to inflammatory mediators (e.g., cytokines, complement, histamine, kinins)
released in a serious infection
Hypovolemia associated with deficient fluid volume resulting from decreased fluid
intake, excessive loss of fluid (can occur with diaphoresis, hyperventilation, vomiting,
and/or diarrhea if present), and the fluid shift that occurs with increased capillary
permeability
200
Decreased cardiac output (occurs late in severe sepsis and shock) associated with the
depressant effect of acidosis, myocardial depressant factor, and some inflammatory
mediators (e.g., cytokines) on myocardial contractility
CLINICAL MANIFESTATIONS
Subjective Objective
Restlessnes Decreased B/P; confusion; cool extremities; pallor or cyanosis of
s extremities; diminished or absent peripheral pulses; slow capillary refill;
edema; oliguria
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RISK FACTORS
Smoking
Hyperlipidemic
Sedentary lifestyle
DESIRED OUTCOMES
The client will maintain adequate tissue perfusion as evidenced by:
a.
b.
c.
d.
e.
201
f.
Absence of edema
g.
NOC OUTCOMES
Circulation status; tissue perfusion: abdominal organs; tissue perfusion: cardiac; tissue
perfusion: cerebral; tissue perfusion: peripheral; tissue perfusion: pulmonary
NIC INTERVENTIONS
Circulatory care: arterial insufficiency; circulatory care: venous insufficiency; cerebral
perfusion promotion; hypovolemia management; cardiac care: acute
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms of
symptoms of diminished tissue ineffective tissue perfusion allows for prompt
perfusion: intervention.
Decreased B/P
Confusion
Cool extremities
202
RATIONALE
Slow capillary refill
Edema
Oliguria
Vital signs
Urine output
203
RATIONALE
ordered to maintain adequate
perfusion pressure and cardiac
output.
Consult appropriate health care Allows for modification of the treatment plan
provider if signs and symptoms of
diminished tissue perfusion
persist or worsen.
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Nursing Diagnosis RISK FOR DEFICIENT FLUID
VOLUME NDx
Definition: At risk for experiencing vascular, cellular, or intracellular dehydration
Related to:
Decreased oral intake associated with anorexia, fatigue, and nausea if present
204
Excessive loss of fluid associated with vomiting and/or diarrhea if present with initial
infection or as a side effect of antimicrobial therapy
Fluid shifting from the intravascular to extravascular space associated with the
increased capillary permeability that occurs with a systemic inflammatory response
CLINICAL MANIFESTATIONS
Subjectiv Objective
e
N/A Decreased B/P; decreased pulse pressure; decreased skin turgor; dry
mucous membranes; increased pulse rate; elevated Hct; increased body
temperature; decreased urine output; increased urine concentration
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DESIRED OUTCOMES
The client will not experience deficient fluid volume as evidenced by:
a.
b.
c.
Stable weight
d.
B/P and pulse rate within normal range for client and stable with position change
e.
f.
g.
205
Balanced intake and output
h.
NOC OUTCOMES
Fluid balance; hydration
NIC INTERVENTIONS
Fluid monitoring; fluid management; hypovolemia management; intravenous therapy;
fever treatment; diarrhea management; nausea management
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and Early recognition of signs and symptoms of
symptoms of deficient fluid volume: deficient fluid volume allows for prompt
intervention.
206
RATIONALE
Change in mental status
207
RATIONALE
Administer prescribed antidiarrheal agents.
CLINICAL MANIFESTATIONS
Subjective Objective
Report of Flushed skin; increase in body temperature; tachycardia; tachypnea;
chills warm to touch
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RISK FACTORS
Illness
208
Dehydration
DESIRED OUTCOMES
The client will experience resolution of hyperthermia as evidenced by:
a.
b.
c.
d.
NOC OUTCOMES
Thermoregulation
NIC INTERVENTIONS
Fever treatment
NURSING ASSESSMENT
RATIONALE
Assess for signs and Early recognition and reporting of signs and symptoms
symptoms of hyperthermia: of hyperthermia allow for prompt intervention.
Tachycardia
209
RATIONALE
Tachypnea
Elevated temperature
Decreases hyperthermia
Dependent/Collaborative Actions
Implement measures to reduce fever:
210
RATIONALE
Treats/prevents infection
Decreases fever
Related to:
211
Break in skin integrity associated with frequent venipunctures or presence of invasive
lines (e.g., intravenous catheter, hemodynamic monitoring devices)
CLINICAL MANIFESTATIONS
Subjective Objective
Verbal reports of pain at areas Increased body temperature; redness, warmth
of impaired skin integrity discharge over areas of impaired skin integrity
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DESIRED OUTCOMES
The client will have resolution of existing infection and remain free of superinfection as
evidenced by:
a.
b.
c.
d.
e.
f.
g.
h.
i.
212
Absence or resolution of heat, pain, redness, swelling, and unusual drainage in any area
j.
k.
l.
m.
NOC OUTCOMES
Immune status; infection severity
NIC INTERVENTIONS
Infection control; infection protection
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of superinfection Early recognition of
(be alert to subtle changes in client since the signs of signs and symptoms of
infection maybe minimal as a result of immunosuppression; an infection allows for
also be aware that some signs and symptoms vary prompt intervention.
depending on the site of the infection, the causative
organism, and the age of the client):
Increase in temperature
213
RATIONALE
214
RATIONALE
Implement measures to prevent
superinfection:
Prevents spread of infection
215
RATIONALE
Prevents introduction of pathogens into the
body
Maintain a closed system for drains (e.g.,
urinary catheter) and intravenous
infusions whenever possible.
216
RATIONALE
Dependent/Collaborative Actions
Implement measures to prevent
superinfection:
217
RATIONALE
CLINICAL MANIFESTATIONS
Subjective Objective
Reports of Low arterial pressure; low systemic vascular resistance; systemic
confusion edema; tachycardia; temperature instability
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DESIRED OUTCOMES
The client will not develop septic shock as evidenced by:
a.
b.
c.
218
Urine output at least 30 mL/h
d.
e.
f.
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of Early recognition of signs and
septic shock: symptoms of septic shock allows for
prompt intervention.
Restlessness
Tachycardia
219
RATIONALE
Systolic B/P less than 90 mm Hg or a
reduction of greater than 40 mm Hg from
baseline
If signs and symptoms of septic Treatment for septic shock focuses on the
shock occur: expansion of circulating volume to improve tissue
perfusion. Oxygenation and perfusion must be
maintained to prevent extreme lactic acidosis. The
Maintain intravenous fluid therapy patient often requires transfer to a critical care unit
as ordered. for invasive monitoring of hemodynamic status
220
RATIONALE
Maintain oxygen therapy (Swan Ganz catheter; central venous pressure;
as ordered. arterial line.)
Administer antimicrobials as
ordered.
Related to: Widespread inflammation and the resulting endothelial damage associated
with sepsis results in inappropriate triggering of the coagulation cascade due to the
presence of tissue factor that is released by damaged or dead tissues
CLINICAL MANIFESTATIONS
Subjective Objective
Reports of Bleeding: rapid development of oozing from
restlessness; agitation; venipuncture sites, arterial lines, surgical wounds; ecchymotic
confusion lesions; bleeding in conjunctiva, nose, and gums
a.
b.
c.
d.
Fibrin degradation products (FDP) and D-dimer results within normal range
e.
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of DIC: Early recognition of signs and
symptoms of DIC allows for
prompt intervention.
Petechiae, ecchymoses
222
RATIONALE
D-dimer.
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THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
If DIC occurs:
The body has depleted its clotting
factors; thus, after any invasive
Implement safety precautions to prevent further procedure, excessive bleeding may
bleeding: occur.
Avoid injections.
Dependent/Collaborative Actions
Implement measures to control infection and Treat/prevent infections
reduce the risk for an uncontrolled systemic
inflammatory response in order to reduce the
risk for DIC:
223
RATIONALE
Perform actions to reduce the risk for
superinfection.
If DIC occurs:
Improves blood's clotting
ability
Administer fresh frozen plasma, platelets, and/or
cryoprecipitate if ordered. Blood products identified help
to enhance clotting and stop
bleeding.
Heparin
Antithrombin III
Relation to:
CLINICAL MANIFESTATIONS
224
Subjectiv Objective
e
N/A Low-grade fever; tachycardia; dyspnea; altered mental status; individual
organ failure
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RISK FACTORS
Malnutrition
Corticosteroids
Bowel infarction
Persistent infection
Burns
Trauma
Acute pancreatitis
225
Circulatory shock
Necrotic tissue
DESIRED OUTCOMES
The client will not develop organ ischemia/dysfunction as evidenced by:
a.
b.
c.
d.
e.
Absence of new or increased abdominal pain, distention, nausea, vomiting, and diarrhea
f.
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of: Early recognition of signs and
symptoms of multiple organ
dysfunction syndrome (MODS)
226
RATIONALE
Cerebral ischemia (e.g., change in mental allows for prompt intervention.
status)
227
RATIONALE
Unfamiliar environment
228
Threat of death
This care plan focuses on the adult client hospitalized for a splenectomy.
The care plan will need to be individualized according to the client's
underlying disease process or the extensiveness of abdominal trauma
necessitating the surgery.
OUTCOME/DISCHARGE CRITERIA
The client will:
1.
2.
3.
4.
229
5.
Identify appropriate safety measures to follow because of increased risk for infection
6.
7.
D = Delegatable Action
= UAP
= LVN/LPN
= Go to for animation
230